Hepatitis A

Hepatitis A

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• Hepatitis A

Key facts

• Hepatitis A is an inflammation of the liver that can cause mild to severe illness.
• The hepatitis A virus (HAV) is transmitted through ingestion of contaminated food and water or through direct contact with an infectious person.
• Almost everyone recovers fully from hepatitis A with a lifelong immunity. However, a very small proportion of people infected with hepatitis A could die from fulminant hepatitis.
• The risk of hepatitis A infection is associated with a lack of safe water and poor sanitation and hygiene (such as contaminated and dirty hands).
• A safe and effective vaccine is available to prevent hepatitis A.

Overview

Hepatitis A is an inflammation of the liver caused by the hepatitis A virus (HAV). The virus is primarily spread when an uninfected (and unvaccinated) person ingests food or water that is contaminated with the faeces of an infected person. The disease is closely associated with unsafe water or food, inadequate sanitation, poor personal hygiene and oral-anal sex.

Unlike hepatitis B and C, hepatitis A does not cause chronic liver disease but it can cause debilitating symptoms and rarely fulminant hepatitis (acute liver failure), which is often fatal. WHO estimates that in 2016, 7134 persons died from hepatitis A worldwide (accounting for 0.5% of the mortality due to viral hepatitis).

Hepatitis A occurs sporadically and in epidemics worldwide, with a tendency for cyclic recurrences. Epidemics related to contaminated food or water can erupt explosively, such as the epidemic in Shanghai in 1988 that affected about 300 000 people (1). They can also be prolonged, affecting communities for months through person-to-person transmission. Hepatitis A viruses persist in the environment and can withstand food production processes routinely used to inactivate or control bacterial pathogens.

Geographical distribution

Geographical distribution areas can be characterized as having high, intermediate or low levels of hepatitis A virus infection. However, infection does not always mean disease because infected young children do not experience any noticeable symptoms.

Infection is common in low- and middle-income countries with poor sanitary conditions and hygienic practices, and most children (90%) have been infected with the hepatitis A virus before the age of 10 years, most often without symptoms (2). Infection rates are low in high-income countries with good sanitary and hygienic conditions. Disease may occur among adolescents and adults in high-risk groups, such as persons who inject drugs (PWID), men who have sex with men (MSM), people travelling to areas of high endemicity and in isolated populations, such as closed religious groups. In the United States of America, large outbreaks have been reported among persons experiencing homelessness. In middle-income countries and regions where sanitary conditions are variable, children often escape infection in early childhood and reach adulthood without immunity.

Transmission

The hepatitis A virus is transmitted primarily by the faecal-oral route; that is when an uninfected person ingests food or water that has been contaminated with the faeces of an infected person. In families, this may happen though dirty hands when an infected person prepares food for family members. Waterborne outbreaks, though infrequent, are usually associated with sewage-contaminated or inadequately treated water.

The virus can also be transmitted through close physical contact (such as oral-anal sex) with an infectious person, although casual contact among people does not spread the virus.

Symptoms

The incubation period of hepatitis A is usually 14–28 days.

Symptoms of hepatitis A range from mild to severe and can include fever, malaise, loss of appetite, diarrhoea, nausea, abdominal discomfort, dark-coloured urine and jaundice (a yellowing of the eyes and skin). Not everyone who is infected will have all the symptoms.

Adults have signs and symptoms of illness more often than children. The severity of disease and fatal outcomes are higher in older age groups. Infected children under 6 years of age do not usually experience noticeable symptoms, and only 10% develop jaundice. Hepatitis A sometimes relapses, meaning the person who just recovered falls sick again with another acute episode. This is normally followed by recovery.

Who is at risk?

Anyone who has not been vaccinated or previously infected can get infected with the hepatitis A virus. In areas where the virus is widespread (high endemicity), most hepatitis A infections occur during early childhood. Risk factors include:

• poor sanitation;
• lack of safe water;
• living in a household with an infected person;
• being a sexual partner of someone with acute hepatitis A infection;
• use of recreational drugs;
• sex between men; and
• travelling to areas of high endemicity without being immunized.

Diagnosis

Cases of hepatitis A are not clinically distinguishable from other types of acute viral hepatitis. Specific diagnosis is made by the detection of HAV-specific immunoglobulin G (IgM) antibodies in the blood. Additional tests include reverse transcriptase polymerase chain reaction (RT-PCR) to detect the hepatitis A virus RNA and may require specialized laboratory facilities.

Treatment

There is no specific treatment for hepatitis A. Recovery from symptoms following infection may be slow and can take several weeks or months. It is important to avoid unnecessary medications that can adversely affect the liver, e.g. acetaminophen, paracetamol.

Hospitalization is unnecessary in the absence of acute liver failure. Therapy is aimed at maintaining comfort and adequate nutritional balance, including replacement of fluids that are lost from vomiting and diarrhoea.

Prevention

Improved sanitation, food safety and immunization are the most effective ways to combat hepatitis A.

The spread of hepatitis A can be reduced by:

• adequate supplies of safe drinking water;
• proper disposal of sewage within communities; and
• personal hygiene practices such as regular handwashing before meals and after going to the bathroom.

Several injectable inactivated hepatitis A vaccines are available internationally. All provide similar protection from the virus and have comparable side effects. No vaccine is licensed for children younger than 1 year of age. In China, a live attenuated vaccine is also available.

WHO response

 

Global health sector strategies on, respectively, HIV, viral hepatitis, and sexually transmitted infections for the period 2022–2030 (GHSSs) guide the health sector in implementing strategically focused responses to achieve the goals of ending AIDS, viral hepatitis (especially chronic hepatitis B and C)  and sexually transmitted infections by 2030.

The GHSS recommend shared and disease-specific country actions supported by actions by WHO and partners. They consider the epidemiological, technological, and contextual shifts of previous years, foster learnings across the disease areas, and create opportunities to leverage innovations and new knowledge for effective responses to the diseases. They call to scale up prevention, testing and treatment of viral hepatitis with a focus to reach populations and communities most affected and at risk for each disease, as well as addressing gaps and inequities. They promote synergies under a universal health coverage and primary health care framework and contribute to achieving the goals of the 2030 Agenda for Sustainable Development.

WHO organizes annual World Hepatitis Day campaigns (as 1 of its 9 flagship annual health campaigns) to increase awareness and understanding of viral hepatitis. For World Hepatitis Day 2023, WHO focuses on the theme “One life, one liver” to illustrate the importance of the liver for a healthy life and the need to scale up viral hepatitis prevention, testing and treatment to prevent liver diseases and achieve the 2030 hepatitis elimination target.

 

Global hepatitis report, 2017

World Hepatitis Day

Global health sector strategy on viral hepatitis

 

 


Publications

• Financing prevention, testing and treatment of hepatitis in the context of Universal Health Coverage
• Guidelines for viral hepatitis planning and tracking progress towards elimination
• Immunological basis for immunization: hepatitis A
• The global prevalence of hepatitis A virus infection and susceptibility
• WHO position paper on hepatitis A vaccines
• More WHO publications

 

More about hepatitis

• WHO’s work on hepatitis
• Global Hepatitis Programme

 

 

Hepatitis A (Hep A) – Treatment

What is hepatitis?

Hepatitis is a general term for inflammation of the liver. Normally, the liver breaks down waste products in your blood. But when the liver is inflamed, it doesn’t do a good job of getting rid of waste products. This causes waste products to build up in your blood and tissues.

Many different things can cause hepatitis. The most common cause of hepatitis is infection with one of the 5 hepatitis viruses (A, B, C, D, or E). Lack of blood supply to the liver, poison, autoimmune disorders, excessive alcohol use, liver injury, and taking certain medicines can also cause hepatitis. Less commonly, viral infections such as mononucleosis or cytomegalovirus can cause hepatitis.

There are 2 main kinds of hepatitis: acute hepatitis and chronic hepatitis. Most people get over the acute hepatitis in a few days or weeks. Sometimes, however, the inflammation doesn’t go away. When the inflammation doesn’t go away in 6 months, the person has chronic hepatitis.

What is hepatitis A?

Hepatitis A (Hep A) is liver inflammation caused by the hepatitis A virus. Hepatitis A is different from other types of hepatitis. It isn’t typically as serious as hepatitis B or C, and it doesn’t usually develop into chronic hepatitis or cirrhosis (late-stage scarring of the liver).

Hepatitis A is very contagious. This means that you can easily catch the virus from someone or give it to someone else. You are most contagious soon after you are infected and before symptoms appear. Adults who are otherwise healthy are no longer contagious 2 weeks after the illness begins. Children and people who have a weak immune system may be contagious for up to 6 months.

Symptoms of hepatitis A

The hepatitis A virus is usually in your system for 2 to 6 weeks before symptoms appear. Some people never have symptoms. If symptoms do appear, they can appear suddenly and may include:

• Nausea
• Vomiting
• Jaundice (the yellowing of the skin and the whites of the eyes)
• Low-grade fever (fever up to 102°F)
• Fatigue
• Pain in your abdomen, especially on your right side
• Dark-colored urine
• Loss of appetite
• Muscle pain

Young children are likely to have mild cases of hepatitis A, while symptoms in older children and adults are more likely to be severe.

What causes hepatitis A?

Hepatitis A is caused by infection with the hepatitis A virus. You get the virus when you unknowingly eat a small amount of infected feces. This can happen through person-to-person contact, or through eating or drinking contaminated food or water.

A person can have and spread hepatitis A, even if that person does not have any symptoms. You are most likely to get hepatitis A from another person when:

• A person who has the virus does not wash their hands properly after going to the bathroom
• A parent does not wash their hands properly after changing the diaper of an infected child
• A caregiver does not wash their hands properly after cleaning up the stool of an infected person
• A person has sex with a person who has the virus

You can also get infected with hepatitis A by eating contaminated food or drinking contaminated water. Contaminated food and water are more common in developing countries. When traveling in areas where hepatitis A is common, avoid eating raw fruits and vegetables, shellfish, ice, and untreated water.

How is hepatitis A diagnosed?

See your doctor if you have any of the symptoms of hepatitis A. They can do a blood test to see if you have the disease.

Hepatitis A treatment

There is no specific medicine to treat or cure hepatitis A. If you have the virus, your body will eventually get rid of the infection on its own. You probably will feel sick for a few months before you begin to feel better.

To help your liver heal, you should get plenty of rest, eat a balanced diet and avoid alcohol and acetaminophen (one brand name: Tylenol). Talk with your doctor before you take any prescription medicines, over-the-counter medicines, vitamins, or supplements. Alcohol, acetaminophen, and certain other medicines, vitamins, and supplements can cause more damage to your liver.

You may need to stay in the hospital for a short time if you get dehydrated, have severe pain, suddenly become confused, or develop bleeding problems.

Can hepatitis A be prevented or avoided?

The best way to protect yourself against hepatitis A is to get the vaccine. The hepatitis A vaccination is recommended for all children older than age 1. It begins to protect you only 4 weeks after you are vaccinated. A 6- to 12-month booster is required for long-term protection. Ask your doctor if the vaccination is right for you.

You should also wash your hands with soap and warm water before and after cooking, after using the bathroom, and after changing diapers.

Wash fruits and vegetables thoroughly before eating and avoid raw or undercooked meat and fish.

You are at higher risk for hepatitis A if you:

• Live with or have sex with someone who has hepatitis A
• Travel to countries where hepatitis A is common
• Are a man who has sex with other men
• Use illegal drugs
• Have a clotting-factor disorder (such as hemophilia)

Living with hepatitis A

Once you recover from hepatitis A, you develop antibodies that protect you from the virus for life, according to the Centers for Disease Control and Prevention.

Questions to Ask Your Doctor

• Do I need treatment?
• What treatment is best for me?
• Will I need be hospitalized?
• Are there any medicines I should avoid taking?
• Are there foods I should avoid eating?
• Can I drink alcohol?
• How can I protect my family from getting hepatitis A?
• If I’ve had hepatitis A, am I at higher risk of getting other types of hepatitis?
• Will I have permanent liver damage?
• How soon before I travel should I be vaccinated?

Resources

American Liver Foundation: Hepatitis A

Hepatitis A: symptoms, diagnosis, treatment

Hepatitis A is an infectious liver disease caused by a virus.

The hepatitis A virus has an acid-resistant envelope. This helps viruses that have entered contaminated food and water to pass the acidic protective barrier of the stomach. The hepatitis A virus is stable in the aquatic environment, so epidemics of hepatitis A are often transmitted by water. The hepatitis A virus is highly immunogenic, after the illness, a stable lifelong immunity is formed.
Hepatitis A is one of the most common human infections. In countries with warm climates and poor sanitation, hepatitis A is very common. It is known that in Central Asia almost all children are ill with hepatitis A. In Eastern Europe, the incidence of hepatitis A is 250 per 100,000 population per year.
The source of infection for is a person with hepatitis A who sheds billions of viruses into the environment through faeces. When drinking water or food contaminated with the hepatitis A virus (especially poorly thermally processed seafood), the viruses enter the intestines, then, being absorbed, they enter the liver with the blood stream and invade its cells – hepatocytes. Virus particles-virions multiply in the cytoplasm of liver cells. After leaving the liver cells, they enter the bile ducts and are excreted with bile into the intestines. The inflammatory process in the liver, leading to damage to hepatocytes, has an immunological basis. Cells of the human immune system, T-lymphocytes, recognize virus-infected hepatocytes and attack them. This leads to the death of infected hepatocytes, the development of inflammation (hepatitis) and impaired liver function.
Hepatitis A virus is transmitted by faecal-oral-water and ingestion. Hepatitis A is most likely to be contracted in hot countries, including those where traditional places of tourism and recreation are located. First of all, these are the countries of Africa (including Egypt and Tunisia), Asia (Turkey, Central Asia, India and Southeast Asia, including the islands), some countries of South America and the Caribbean. Hepatitis A is primarily a childhood infection. Many children carry the infection in an anicteric form and hepatitis A is not recognized during this period.
In developed countries, hepatitis A, also called “dirty hands disease “, is difficult to get sick due to the high culture of the population and the excellent work of communal services. Therefore, there are very few people who have antibodies to this infection, and the risk of getting sick upon contact with the hepatitis A virus is quite high. More often this happens during business trips and tourist trips to hot countries, to African and Asian resorts, to the republics of Central Asia.

When buying vegetables and fruits in the market, do not forget to wash them properly , always cook seafood.
Healthy people can be in contact with the sick, observing the elementary rules of hygiene. However, it is better to isolate children from patients.

To determine the likelihood and degree of risk of infection with , but rather to decide whether vaccination is necessary, a blood test for the presence of antibodies to the hepatitis A virus of the immunoglobulin G class ( anti – HAV IgG ) is carried out. If these antibodies are found in the blood, then contact with the virus was: infection or vaccination. This means that you have immunity to the virus, which means that the risk of infection is zero and vaccination against hepatitis A is not needed. It is almost impossible to get hepatitis A again. If there are no antibodies, then there is a risk. You need a vaccination. There is a special drug – immunoglobulin, which can be administered immediately before a possible infection or within 2 weeks after infection. This will allow for a short time to protect either from infection or from the development of the disease in case of infection.

Risk of contracting hepatitis A , and when vaccination is necessary (vaccination against hepatitis A):

• Family members (household) of a person infected with hepatitis A virus
• Persons who have sex with an infected person
• People (especially children) living in areas with a high prevalence of hepatitis A
• Travelers traveling to countries with a high incidence of hepatitis A

What if there is a patient with hepatitis A in the family?

It is recommended that all family members be screened for antibodies to hepatitis A (anti-HAV IgG). In the absence of these antibodies, vaccination is necessary. Remember to follow the simplest rules of hygiene: wash your hands with soap and water after using the toilet and using the bathroom, after caring for a small child, before eating and preparing food.

Hepatitis A Clinic

Within a month (incubation period 15-50 days, on average 30) after the alleged infection, the main symptoms can be expected: fever, dyspepsia (nausea, vomiting, heaviness in the stomach and right hypochondrium), weakness, darkening urine (the color of strong brewed tea, frothiness) and then jaundice – yellowing of the sclera, skin, discoloration of feces. After the onset of jaundice, the general condition often improves slightly. Jaundice lasts about 3-6 weeks, sometimes longer. The disease lasts on average about 40 days. This largely depends on age, the state of immunity, the presence of concomitant chronic diseases, and the strict implementation of the doctor’s recommendations. Some people (about 15%) have a long-term course of hepatitis A, within 6-9months. Recovery usually follows. Most cases of hepatitis A have typical symptoms, leading to recovery.

Infection is severe in children under one year of age , adults and the elderly. In adults, the infection often proceeds with severe intoxication and jaundice, on average they get sick for about 3 months. The risk of death in hepatitis A is 0.1% in children, 0.3% in adolescents and adults. All acute hepatitis of any origin are manifested by the same signs, so you need to see a doctor and conduct a full examination.

Diagnosis of hepatitis A

In addition to collecting an epidemiological history (where the person was during the last month, what he ate, what water he drank, whether he had contact with patients with jaundice, etc.) and examination, test results are required (complete blood count, biochemical blood tests, analysis for markers of viral hepatitis, coagulogram, urinalysis).

The criterion for diagnosing acute hepatitis A is the presence in human blood of antibodies to hepatitis A related to class M immunoglobulins (anti – HAV IgM). These antibodies are found only in the acute period, with recovery, their titer decreases.

Hepatitis A treatment

Modern treatment is more focused not on fighting hepatitis A viruses, but on reducing the concentration and removal from the body of harmful substances that appear when the liver is damaged and functions are impaired. Therefore, detoxification solutions, glucose, vitamins, hepatoprotectors (drugs that protect liver cells) are administered. The decision to prescribe special antiviral therapy is made by the doctor. Hepatitis A ends with recovery.
The prognosis is favorable, liver function is usually fully restored. In the acute period, it is necessary to adhere to a sparing diet, physical and mental rest is observed.

Prevention of hepatitis A, vaccination

Quite effective vaccines have been developed to protect against hepatitis A. These vaccines are killed hepatitis A viruses and are highly immunogenic. The vaccine is administered twice with an interval of 6-12 months. After the first dose of the vaccine, antibodies to the hepatitis A virus appear in most vaccinated people after 2 weeks. The duration of protection by vaccination is at least 6-10 years.

Hepatitis A vaccination is indicated for children over 3 years of age and adults who have not previously had hepatitis A, as well as people with an increased risk of infection: – traveling to areas with a high level of hepatitis A transmission (tourists, contractors, military personnel) – medical personnel of infectious departments – educators and staff of preschool institutions – catering and water supply workers. – Patients with chronic liver disease. According to the regulations of the Ministry of Health, children living in areas with a high incidence of hepatitis A are subject to vaccination.

Attention! Consult a doctor for vaccination!

Which hepatitis can be cured and which cannot be cured? the virus causes a completely different disease.

What are hepatitis A and E viruses?

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Hepatitis A and E viruses belong to the group of viruses with an enteral mechanism of infection. It implies infection “through the mouth.” They are the least dangerous from the point of view of the patient. These viruses always cause an acute illness, never turning into a chronic one.

Hepatitis A is Botkin’s disease, or “dirty hands disease”, it occurs when eating dirty food or water.

A patient with hepatitis A or E almost always recovers and develops lifelong immunity to infection. However, fulminant hepatitis, which is acute liver necrosis, can become a complication. In this case, liver failure appears, often leading to the death of the patient.

There is no specific treatment for hepatitis A and E. However, there are effective and safe preventive vaccines. The hepatitis A vaccine was invented a long time ago, however, it is not on the vaccination calendar in our country. It is known that during outbreaks of hepatitis A there is practically no infection of those who are vaccinated against this infection. And I, for one, am vaccinated.

Hepatitis E is a rarer hepatitis in developed countries with a similar route of infection. A vaccine was created against this virus in China several years ago, but so far it has been approved only in this country.

Hepatitis B and C

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There are also hepatitis B and C viruses that belong to the group of parenteral infections. They become infected through the blood: with intravenous drug use, medical procedures with the use of poorly sterilized instruments, infected blood during transfusions, and so on. Hepatitis B and C viruses cause chronic liver disease in most cases.

According to current estimates, there are about 240 million people with chronic hepatitis B in the world. exceeds 5%. The danger of chronic hepatitis B is that almost a third of patients develop cirrhosis and / or liver cancer.

Against the hepatitis B virus, scientists have developed a preventive vaccine that is safe and provides very good protection against infection. It is based on protein rather than infectious material and is well tolerated by humans. Interestingly, there is now a combination vaccine for hepatitis A and B.

The hepatitis C virus was discovered the latest – in 1989, when I was in the second grade. This virus is extremely difficult for laboratory research. In the case of other viruses, scientists usually take a cell line and try to infect it. And the hepatitis C virus, as it turned out, is not able to develop in almost any standard cell line. In general, research on the hepatitis C virus has been greatly hampered.

An incomplete cellular model was obtained only in 1999.

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A complete infectious model appeared only in 2005 – very recently. But by now, scientists know all the key mechanisms for the development of infection in a cell: from infection to the assembly of new viral particles.

We know that this is a very common virus. Why? Most likely, because in most cases the disease begins asymptomatically. Now, according to various sources, 130–150 million people have chronic hepatitis C. In Russia, according to some data, up to 3% of the population suffer from it. In 4/5 cases, hepatitis C becomes chronic. And even in the chronic stage, this virus can be asymptomatic – and it can only be diagnosed by special tests.

Like hepatitis B, hepatitis C is extremely dangerous: it often leads to fibrosis and cirrhosis of the liver. And in a number of patients, eventually – to cancer. As far as I know, the treatment of liver cancer is not very effective and can only be saved from it by transplantation. It is believed that up to 80% of all patients with cirrhosis and liver cancer are patients with chronic hepatitis B and C. There is evidence that even patients who have recovered from hepatitis C have an increased risk of getting cirrhosis or liver cancer.

How to be treated for hepatitis B and C?

Hepatitis B is treated quite poorly. That is, it is easy to suppress, but almost impossible to cure, because it has the so-called ccDNA – double-stranded circular DNA. And it is not yet known how to remove it from already infected cells. Several types of substances are used to suppress infection: nucleoside analogs and interferon alfa and its pegylated forms. However, they do not always work.

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Recently, a drug has been developed against hepatitis B based on inhibition of the cell receptor with which the virus interacts. In the early 2000s, scientists first found a cell line that reproduces the full cycle of the hepatitis B virus and identified the NTCP receptor, the bile acid receptor. And it turned out that when interacting with this receptor, the hepatitis B virus enters the body. Then the researchers took peptides that mimic a fragment of the viral protein that is responsible for binding to it, and developed a drug that is now undergoing clinical trials.

However, all these drugs cannot cure people with chronic hepatitis B.

Unlike hepatitis B, hepatitis C can be cured. He is now responding very well to treatment. Patients are considered cured if, 24 weeks after the end of therapy, viral RNA is not detected by sensitive test systems. In the 2000s, therapy was based on interferon alfa – treatment lasted up to 48 weeks, was very difficult for the patient and ineffective. Six months later, the patient was checked, if he did not have the virus, the patient was considered completely healthy. Then scientists developed direct-acting antiviral drugs, that is, not aimed at the proteins of the virus.

Thanks to them, the number of recoveries (percentage of cure / effectiveness of therapy) has increased.

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And, importantly, the treatment time has been reduced. Currently, there are combinations of direct-acting drugs that can cure up to 99% of patients with a virus of any genotype, and without the use of interferon. It became possible to treat, among other things, HIV-infected patients, who previously represented a separate cohort of patients. Doctors now treat them simply by considering the interactions of hepatitis drugs with antiretroviral drugs. It became possible to treat patients with cirrhosis of the liver, as well as patients before liver transplantation. And this is a huge breakthrough in science.

By the way, I personally work in a laboratory that investigates the metabolic processes during infection with the hepatitis C virus. Although patients can be cured, it is impossible to completely eliminate the risk of cirrhosis, fibrosis and liver cancer. These risks remain. We are exploring metabolic pathways and finding out how the virus affects them and whether it is possible to make a substance that can suppress the pathogenicity of the virus.

Hepatitis D virus, or Parasite on parasite

Hepatitis D virus (or delta virus) is a satellite virus. It was discovered a long time ago by an Italian group of scientists who were trying to find out why patients with chronic hepatitis B had different course and severity of the disease in northern and southern Italy. And the Italians found that patients with a severe course of the disease have some additional delta antigen. Then scientists realized that it was a satellite virus, that is, an incomplete virus. If an ordinary virus is a parasite to a cell, then it is a parasite to a parasite. It carries a short circular RNA and encodes only one antigen (protein). This antigen can be in two different forms – but still it is encoded by a single gene.

This protein can form a virus capsid – the inner shell of a viral particle, but it is not enough to form a full-fledged own virion. To form a viral particle, this virus uses the envelope proteins of the hepatitis B virus. The delta virus protein does not have enzymatic activity, and it uses the host cell apparatus to replicate its genome.

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The number of people infected with delta hepatitis in the world is estimated at 15 million people. There are two different types of infection – coinfection and superinfection.

Co-infection is the simultaneous infection with hepatitis B and delta viruses, and superinfection is the infection of hepatitis D in patients with already established chronic hepatitis B.

In each case, the course of the disease will be different. With coinfection, 95% of cases will develop acute hepatitis, but there will be no chronic disease. But at the same time, there is a fairly high probability of developing the already mentioned fulminant hepatitis.