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Causative Agent

Hepatovirus (hepatitis A), orthohepadnavirus (hepatitis B), hepacivirus (hepatitis C), deltavirus (hepatitis D) and hepevirus (hepatitis E).

Incubation Period

See Table.

Infectious Period

See Table.


See Table.


Hepatitis A, B, C and E are endemic in Singapore.

A total of 253 cases of serologically confirmed acute viral hepatitis were reported in 2009. Of these, 111 (44%) were imported. There were 89 cases of hepatitis A (35%), 69 cases of hepatitis B (27%), 5 cases of hepatitis C (2%) and 90 cases of hepatitis E (36%). No deaths were reported.

  • Fever
  • Anorexia, nausea, vomiting
  • Right hypochondrial pain
  • Jaundice
  • Dark urine, pale stools
  • Hepatomegaly

See Table for description of sequelae.

Common biochemical abnormalities shared by the viral hepatitides:

  • Leucopenia
  • Urine urobilin, urobilinogen
  • Raised serum bilirubin and transaminase levels (ALT > AST)
  • Raised gamma-GT

  • Hepatitis A: IgM antibodies become detectable when jaundice develops and persist for approximately 3 months.
  • Hepatitis B: In acute hepatitis B, HBsAg is present in serum. However, it is also present in long-term carriers of HBV. The diagnosis of acute disease is confirmed by demonstrating IgM anti-HBc antibody in serum. This appears 2 weeks after HBsAg and disappears a few months after uncomplicated infection.
  • HCV: Diagnosis depends on the detection of antibodies to recombinant antigens and detection of viral RNA (e.g. by PCR techniques).

A legally notifiable disease in Singapore. Notify Ministry of Health (Form MD 131 or electronically via CD-LENS) not later than 72 hours from the time of diagnosis.

There is no specific anti-viral therapy indicated for acute viral hepatitis. Management is symptomatic and supportive. Treatment is available for chronic carriers of hepatitis B and C. Consider referral to a hepatologist.

Contact precautions should be observed for hepatitis A and E. Universal precautions should be observed for hepatitis B, C and D.

  • Hepatitis A
    • All susceptible persons travelling to or working in countries that have high or intermediate hepatitis A endemicity should be vaccinated.
    • One dose of monovalent vaccine (HAVRIX 0.5mL for 1-18 years old and 1.0mL for ≥ 19 years old) should be administered any time before departure (ideally with IG if given ≤ 2 weeks for older adults, immunocompromised persons and persons with chronic medical condition).
    • Completion of vaccination (2nd dose at 6-12 months) is necessary for long term protection.
    • Travellers who are less than 12 months of age, are allergic to a vaccine component, or who otherwise elect not to receive vaccine should receive a single dose of IG (0.02mL/kg), which provides effective protection against HAV infection for up to 3 months.
    • Boiling or cooking food and beverage for at least 1 minute to 85°C inactivates HAV.
  • Contact tracing of the source of infection and the mode of transmission will be carried out for acute cases. In common source outbreaks of hepatitis A, special attention will be given to contaminated food, especially imported shellfish.
  • Hepatitis B
    • Vaccination against Hepatitis B is routinely given to all newborns  (see Childhood Immunisation Programme in Appendix 2), healthcare personnel and other population groups at risk. Seronegative contacts of acute hepatitis B cases and carriers should also be vaccinated.
    • An accelerated vaccine schedule could be used for those travelling to endemic areas at short notice and facing imminent exposure because of behavioural risks or to emergency responders to disaster areas. The monovalent hepatitis B vaccine can be used at 0, 7, and 14 days. Patient should receive a booster at least 6 months after the start of the vaccination series.
    • Prevention of hepatitis B requires the use of disposable needles and syringes and use of sterile equipment for parenteral injections, acupuncture, tattooing and other procedures where skin is punctured. Observing universal precautions is the cornerstone of prevention in the healthcare setting.
  • Transfusion hepatitis B and C are prevented by screening of blood donors.
  • Post-Exposure Management (See Table).
  • Notify all childhood hepatitis B vaccinations to the National Immunisation Registry, Health Promotion Board, and post-vaccination adverse reactions to the Pharmacovigilance Branch, Health Sciences Authority.




 Clinical Sequelae

 Transmission Route




15 - 50 days

2 - 3 weeks
before and 1 week after onset of

No chronic sequelae.

Food and water borne

Anti-HAV IgM +

PEP/vaccine available


45 - 160 days

Many weeks before onset of symptoms to months or years after jaundice in chronic carriers

Sequelae of chronic HBV infection includes liver cirrhosis, chronic active hepatitis (CAH), chronic persistent hepatitis (CPH) and hepatocellular carcinoma (HCC) as well as hepatitis D superinfection.

Blood and body fluids, parenteral, perinatal, sexual

HBsAg +,
HBeAg +/-, Anti-HBc IgM + (CAH, CPH
diagnosed by liver biopsy) HBV DNA PCR

PEP/vaccine available


2 - 15 weeks

As in HBV

Sequelae of chronic HCV infection includes HCC, CAH, CPH and liver cirrhosis.

Blood and body fluids, parenteral, perinatal (uncommon), sexual (not well

Anti-HCV IgG + HCV PCR +

No PEP/ vaccine available


2 - 8 weeks

As in HBV

Simultaneous infection with
HBV and HDV may lead to severe or fulminant hepatitis.

As in HBV; co-infection with
HBV or super-infection in a chronic HBV carrier.

Anti-HDV IgM+ and IgG+

Vaccine to
prevent HBV infection


4 - 8 weeks

As in HAV

No chronic sequelae. Higher incidence of fulminant disease
than hepatitis A. High mortality in pregnant women.

Mainly water-borne

Anti-HEV Ig M +

No PEP/vaccine available

HAV - Hepatitis A virus

HCV - Hepatitis C virus

HEV - Hepatitis E virus

HBV - Hepatitis B virus

HDV - Hepatitis D virus

PEP - Post-Exposure Prophylaxis

Exposed HCW

When source is found to be :

HBsAg +

HBsAg -



Administer HBIGx1 and initiate
HB vaccine

Initiate HB vaccine

Initiate HB vaccine

Previously vaccinated

  • Known responder

Test exposed person for anti-HBs

  • Adequate, no prophylaxis
  • Inadequate, HB vaccine booster dose
No prophylaxis No prophylaxis
  • Known non- responder
HBIG plus 1 dose of HB vaccine to start new course of HB vaccination RevaccinateIf high-risk source, may treat as if source were HBsAg +
  • Response unknown

Test exposed person for anti-HBs

  • Adequate, no prophylaxis
  • Inadequate, HBIG plus HB vaccine booster dose

Test exposed person for anti-HBs

  • Adequate, no prophylaxis
  • Inadequate, HB vaccine booster dose

HBIG - Hepatitis B Immune Globulin dose 0.06 ml/Kg intramuscularly
Adequate anti-HBs is > 10 mIU/ml
Recommended for HCW is > 100 mIU/ml
Booster is recommended if < 100 mIU/ml


  1. CDC. Prevention of hepatitis A through active or passive immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55(RR07):1-23.
  2. Ministry of Health. Hepatitis B immunisation: long-term immunogenicity of low dose yeast-derived recombinant hepatitis B vaccine. Epidemiol News Bull 2010;36:46-52.
  3. Chow WC,Tien SL, Tan CK et al. Treatment of chronic hepatitis C in patients with end-stage renal disease and haemophilia - the Singapore experience. Intervirology 2006; 49: 107-11.
  4. Winslow M, Subramaniam M, Ng WL et al. Seroprevalence of hepatitis C in intravenous opioid users presenting in early phase of injecting drug use in Singapore. Sing Med J 2007;48:504-8.
  5. Hong WW, Ang LW,Cutter J et al. Changing seroprevalence of hepatitis B virus markers of adults in Singapore. Ann Acad Med Singapore 2010;39:591-8.

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