Childhood Infectious Diseases Dr Elham Bukhari Dr Elham Bukhari Assistant Professor & Consultant Pediatric Infectious Diseases King Khalid University Hospital King Saud University, Riyadh

Common Viral Infecions Measles Mumps Rubella Chicken pox (Fifth Disease) Erythema infectiousum (Fifth Disease) Roseola infantum(Sixth Disease)

Rashes caused by childhood infections. Macular/papular /maculopapular: Macules-red/pink discrete flat areas,blanch on pressure ex rubella,measles..ect Papules –solid raised hemispherical lesions,usually tiny,also blanch on perssure.ex scarlet fever,kawasaki disease. Purpuric/petechial: Non-blanching red/purple spots.ex meningococcal.

Vesicular: Raised hemispherical lesions,<0.5 cm diameter,contain clear fluid.ex chicken pox Pustular/bullous: Raised hemispherical lesions,>0.5cm diameter,contain clear or purulent fluid. ex Imptigo

Cont…… Desquamation: Dry and flaky loss of surface epidermis, often peripheries. ex Kawasaki disease.

Measles RNA Virus RNA Virus Incubation Period: 6 – 12 days Incubation Period: 6 – 12 days Clinical Features.fever,rash,coryza Clinical Features.fever,rash,coryza Complications: Complications: Respiratory: pneumonia,om Respiratory: pneumonia,om Neurological:febrile conv.encephalitis,SSPE Neurological:febrile conv.encephalitis,SSPE Others:diarrhoea,hepatitis Others:diarrhoea,hepatitis Treatment;symptomatic Treatment;symptomatic Isolation & Infectivity: 2 days before till 6 days after rash Isolation & Infectivity: 2 days before till 6 days after rash

CLINICAL MANIFESTATIONS 1.Incubation period is approximately 6~18days,10days is the most common. (3-4weeks) 2. 2.predromal phase 3~4 days. 3~4 days Fever. 2. Catarrhal inflammation of URT. 3. Koplik’s spots.. 4. Transient prodromal rashes. yy:

3. Eruption stage 3. Eruption stage 1. Time: the 3~5 days after fever ; but the 4th day is most common; 1. Time: the 3~5 days after fever ; but the 4th day is most common; 2. Shape: maculopapular 2. Shape: maculopapular 3. Sequence: behind the ear→along the hairline→face→neck→chest→back→abdomen→limbs→hand and feet(palm, sole) 3. Sequence: behind the ear→along the hairline→face→neck→chest→back→abdomen→limbs→hand and feet(palm, sole) 4. The temperature rise continuously and accompanied with the toxic symptoms. 4. The temperature rise continuously and accompanied with the toxic symptoms Convalescent stage brown staining. fine desquamation. course:10-14 days

COMPLICATIONS : 1.Bronchopneumonia. 2.Myocarditis. 3.Laryngitis. 4.Neurologic complications: Encephalitis and SSPE. subacute sclerosing panencephalitis Persistent infection of the brain. Rare,psychologic.neuro deterioration. Personality changes,seziure,coma.

Measles (cont.) Koplik’s spots

Measles (Cont.)

Measles vs. Scarlet fever

DIAGNOSIS. 1.Epidemiologic data. 2.Clinical manifestations. 3. Laboratory findings: Multinucleated giant cells are detected in nasopharyax mucosa secretions. 2.Measles virus can be isolated in tissues culture.. specific antibody IgM.. 3. Antibody titer. specific antibody IgM. 4. Other Ag and multinucleated giant cells

EPIDEMIOLOGY 1.Source of infection 1.Source of infection The patients are the only source of infection. The patients are the only source of infection. 2.Routes of transmission 2.Routes of transmission air-borne air-borne 3. Susceptibility of population 3. Susceptibility of population 1. All age person is susceptible; 90% of contact people acquire the disease. 1. All age person is susceptible; 90% of contact people acquire the disease. 2.The permanent immunity acquire after disease. 2.The permanent immunity acquire after disease. 4.Epidemic features 4.Epidemic features season:winter and spring season:winter and spring age:6 months to 5 years old age:6 months to 5 years old

DIFFERENTIAL DIAGNOSIS DIFFERENTIAL DIAGNOSIS 1.Rubella (German measles) 2. scarlet fever. 3.Roseola infantum (infant subitum,exanthem subitum) 4. Drug rashes.

Mumps RNA Virus RNA Virus Incubation Period: 14 – 21 days Incubation Period: 14 – 21 days Clinical Features:fever,sweeling Clinical Features:fever,sweeling Complications: Complications: Glandular Glandular Non glandular Non glandular Isolation & Infectivity: 9 days after onset of parotid swelling Isolation & Infectivity: 9 days after onset of parotid swelling

Clinical manifestation of mumps are: Parotid inflammation (or parotitis) in 60–70% of infections and 95% of patients with symptoms Parotitis causes swelling and local pain, particularly when chewing. It can occur on one side (unilateral) but is more common on both sides (bilateral) in about 90% of cases. ParotidinflammationparotitisParotitis Fever Headache Pancreatitis: inflammation of the affected pancreas. Pancreatitis Orchitis: painful inflammation of the testicles Orchitis

Diagnosis : Person infected with mumps is contagious from approximately 6 days before the onset of symptoms until about 9 days after symptoms start. Usually the disease is diagnosed on clinical grounds and no confirmatory laboratory testing is needed

Rubella RNA Virus RNA Virus Incubation Period: 14 – 21 days Incubation Period: 14 – 21 days Clinical Features:fever,rash. Clinical Features:fever,rash. Complications: Complications: Acquired ;arthritis,encephalitis, Acquired ;arthritis,encephalitis, Congenital:fetal damage. Congenital:fetal damage. Isolation & Infectivity: 7 days from onset of rash Isolation & Infectivity: 7 days from onset of rash Congenital Rubella: until 1 year of age Congenital Rubella: until 1 year of age

Rubella Symptoms include: low grade fever, swollen glands (sub occipital & posterior cervical lymphadenopathy), joint pains, headache and conjunctivitis. The swollen glands or lymph nodes can persist for up to a week and the fever rarely rises above 38 o C (100.4 o F). The rash of German measles is typically pink or light red. The rash causes itching and often lasts for about three days.glandslymph nodesfever

Rubella (Cont.)

Congenital rubella syndrome Congenital rubella syndrome Rubella can cause CRS in the newly born. The syndrome (CRS) follows intrauterine infection by the Rubella virus and comprises cardiac, cerebral, ophthalmic and auditory defects. It may also cause prematurity, low birth weight, and neonatal thrombocytopenia, anaemia and hepatitis. The risk of major defects or organogenesis is highest for infection in the first trimester.first trimester

Congenital Rubella Syndrome

Chicken Pox (Varicella) DNA Virus(VZV). Incubation Period: 10 – 21 days Clinical Features:Papules-vesicles-pusules- crusts. Complications: 2 nd bacterial infection:staph.strep Neurological :cerebellitis, encephalitis Reye syndrome Disseminated:immunocompromised Treatment: (Acyclovir).ZIG. Isolation & Infectivity: 2 days before rash till all skin lesions have crusted (6 th day of rash)

Cont. Chicken Pox

Rubella, Smallpox, Chickenpox

Poliovirus Incubation Period: 7 – 21 days Incubation Period: 7 – 21 days Clinical Features: <1% classical paralytic polio Clinical Features: <1% classical paralytic polio Complications: aseptic meningitis. Complications: aseptic meningitis. Treatment Treatment Isolation & Infectivity: several weeks Isolation & Infectivity: several weeks

What is Poliomyelitis? polio= gray matter polio= gray matter Myelitis= inflammation of the spinal cord Myelitis= inflammation of the spinal cord This disease result in the destruction of motor neurons caused by the poliovirus. This disease result in the destruction of motor neurons caused by the poliovirus. Polio is causes by a virus that attacks the nerve cells of the brain & spinal cord although not all infections result in sever injuries and paralysis. Polio is causes by a virus that attacks the nerve cells of the brain & spinal cord although not all infections result in sever injuries and paralysis.

How is polio transmitted? Poliovirus is transmitted through both oral and fecal routes with implantation and replication occurring in either the oropharyngeal and or in the intestine of mucosa. Poliovirus is transmitted through both oral and fecal routes with implantation and replication occurring in either the oropharyngeal and or in the intestine of mucosa. Polio cases are most infected for 7-10 days before and after clinical symptoms begin. Polio cases are most infected for 7-10 days before and after clinical symptoms begin.

What are the symptoms? Many include fever, pharyngitis, headache, anorexia, nausea, and vomiting. Illness may progress to aseptic meningitis and menigoencephalitis in 1% to 4% of patients. These patients develop a higher fever, myalgia and sever headache with stiffness of the neck and back. Many include fever, pharyngitis, headache, anorexia, nausea, and vomiting. Illness may progress to aseptic meningitis and menigoencephalitis in 1% to 4% of patients. These patients develop a higher fever, myalgia and sever headache with stiffness of the neck and back.

Can it cause paralytic disease? Paralytic disease occurs 0.1% to 1% of those who become infected with the polio virus. Paralysis of the respiratory muscles or from cardiac arrest if the neurons in the medulla oblongata are destroyed. Patients have some or full recovery from paralysis usually apparent with proximally 6 months Physical therapy is recommended for full recovery.

Polio Vaccines OPV IPV

Vaccine Polio vaccine first appeared to be licensed in the United States in Advantages: Ease to administration Good local mucosal immunity Disadvantage: Strict cold shipping & storage requirements Multiple doses required to achieve high humeral conservation rates against all virus types

Vaccine (continuation) Babies are given 4 doses through out their infancy. Babies are given 4 doses through out their infancy. Adolescents and adults should get vaccinated as well. Adolescents younger than 18 should receive the routine four doses. Adolescents and adults should get vaccinated as well. Adolescents younger than 18 should receive the routine four doses. You should get it if you travel outside places where polio id still an epidemic You should get it if you travel outside places where polio id still an epidemic

Treatment Bed rest with close monitoring of respiratory and cardiovascular functioning is essential during the acute stage of poliomyelitis along with fever control and pain relievers for muscle spasms. Bed rest with close monitoring of respiratory and cardiovascular functioning is essential during the acute stage of poliomyelitis along with fever control and pain relievers for muscle spasms. Mechanical ventilation, respiratory therapy may be needed depending of the severity of patients. Mechanical ventilation, respiratory therapy may be needed depending of the severity of patients.

Croup Parainfluenza Parainfluenza Incubation Period: 2 – 6 days Incubation Period: 2 – 6 days Clinical Features Clinical Features Complications Complications Treatment Treatment Isolation & Infectivity: contact precaution in hospital, infective up to 3 weeks Isolation & Infectivity: contact precaution in hospital, infective up to 3 weeks

Croup (or laryngotracheobronchitis) is a respiratory condition that is usually triggered by an acute viral infection of the upper airway. The infection leads to swelling inside the throat, which interferes with normal breathing and produces the classical symptoms of a "barking" cough, stridor, and hoarseness coughstridorhoarseness

croup Croup is characterized by a "barking" cough, stridor, hoarseness, and difficult breathing which usually worsens at night.coughstridor hoarsenessdifficult breathing The "barking" cough is often described as resembling the call of a seal or sea lion.sealsea lion The stridor is worsened by agitation or crying, and if it can be heard at rest, it may indicate critical narrowing of the airways. As croup worsens, stridor may decrease considerablycrying

Diagnosis The first step is to exclude other obstructive conditions of the upper airway, especially epiglottitis, an airway foreign body, subglottic stenosis, angioedema, retropharyngeal abscess, and bacterial tracheitis. The first step is to exclude other obstructive conditions of the upper airway, especially epiglottitis, an airway foreign body, subglottic stenosis, angioedema, retropharyngeal abscess, and bacterial tracheitis.epiglottitisforeign bodysubglottic stenosisangioedemaretropharyngeal abscessbacterial tracheitisepiglottitisforeign bodysubglottic stenosisangioedemaretropharyngeal abscessbacterial tracheitis

Diagnosis A frontal X-ray of the neck is not routinely performed, but if it is done, it may show a characteristic narrowing of the trachea, called the steeple sign, because of the subglottic stenosis, which is similar to a steeple in shape A frontal X-ray of the neck is not routinely performed, but if it is done, it may show a characteristic narrowing of the trachea, called the steeple sign, because of the subglottic stenosis, which is similar to a steeple in shapeX-raysteeple signsteepleX-raysteeple signsteeple

signsteeple sign. steeple sign

Croup treatment: Corticosteroids, such as dexamethasone and budesonide, have been shown to improve outcomes in children with all severities of croup, single dose is usually all that is required. Corticosteroidsdexamethasonebudesonide Moderate to severe croup may be improved temporarily with nebulized epinephrinenebulizedepinephrine

Bronchiolitis Respiratory Syncytial Virus Respiratory Syncytial Virus Incubation Period: 2 – 8 days Incubation Period: 2 – 8 days Clinical Features Clinical Features Complications Complications Treatment Treatment Isolation & Infectivity: 3 – 8 days (up to 4 weeks in infants) Isolation & Infectivity: 3 – 8 days (up to 4 weeks in infants)

Bronchiolitis most often affects infants and young children because their small airways can become blocked more easily than those of older kids or adults typically occurs during the first 2 years of life, with peak occurrence at about 3 to 6 months of age is more common in males, children who have not been breastfed, and those who live in crowded conditions.

Signs & Symptoms Sudden breathing difficulty, usually preceded by fever and a mild common cold and cough, and characterized by the following: Sudden breathing difficulty, usually preceded by fever and a mild common cold and cough, and characterized by the following: Wheezing. Wheezing. Rapid, shallow breathing (60 to 80 times a minute). Rapid, shallow breathing (60 to 80 times a minute). Retractions (seesaw movements) of the chest and abdomen, and nasal flaring. Retractions (seesaw movements) of the chest and abdomen, and nasal flaring. Fever (occasionally). Fever (occasionally). Blue discoloration of skin or nails (severe cases). Blue discoloration of skin or nails (severe cases).

Treatment General Measures Keep the humidity in the child's room as high as possible, preferably with an ultrasonic cool-mist humidifier. Clean humidifier daily. If you don't have a humidifier, run cold or hot water in the shower with windows and doors closed to produce a high-humidity room. Hold the child in this room for 20 minutes several times a day, especially at bedtime. If the child awakens at night with wheezing or shortness of breath, repeat the process.

Erythema Infectiosum (Fifth Disease) Parvovirus B19 Parvovirus B19 Incubation Period: 4 – 21 days Incubation Period: 4 – 21 days Clinical Features:fever,,slapped cheek rash. Clinical Features:fever,,slapped cheek rash. Complications:aplastic crises Complications:aplastic crises Treatment Treatment Isolation & Infectivity: droplet precautions for 7 days Isolation & Infectivity: droplet precautions for 7 days

disease symptoms Fifth disease symptoms Bright red cheeks are a defining symptom of the infection in children (hence the name "slapped cheek disease"). Occasionally the rash will extend over the bridge of the nose or around the mouth. Bright red cheeks are a defining symptom of the infection in children (hence the name "slapped cheek disease"). Occasionally the rash will extend over the bridge of the nose or around the mouth.cheeksrashcheeksrash In addition to red cheeks, children often develop a red, lacy rash on the rest of the body, with the upper arms and legs being the most common locations. In addition to red cheeks, children often develop a red, lacy rash on the rest of the body, with the upper arms and legs being the most common locations.

Fifth disease

Roseola (Sixth Disease) HHV-6 HHV-6 Incubation Period: 9 – 10 days Incubation Period: 9 – 10 days Clinical Features:fever followed by macular rash as fever wanes. Clinical Features:fever followed by macular rash as fever wanes. Complications;associate e febrile convulsion Complications;associate e febrile convulsion Treatment Treatment

Roseola Typically the disease affects a child between six months and two years of age, and begins with a sudden high fever (39–40 °C; °F). Typically the disease affects a child between six months and two years of age, and begins with a sudden high fever (39–40 °C; °F).fever This can cause, in rare cases, febrile convulsions (also known as febrile seizures or "fever fits") due to the sudden rise in body temperature, but in many cases the child appears normal. This can cause, in rare cases, febrile convulsions (also known as febrile seizures or "fever fits") due to the sudden rise in body temperature, but in many cases the child appears normal. febrile seizures febrile seizures After a few days the fever subsides, and just as the child appears to be recovering, a red rash appears. This usually begins on the trunk, spreading to the legs and neck. The rash is not itchy and may last 1 to 2 days After a few days the fever subsides, and just as the child appears to be recovering, a red rash appears. This usually begins on the trunk, spreading to the legs and neck. The rash is not itchy and may last 1 to 2 days

Infectious Mononucleosis Epstein-Barr Virus Epstein-Barr Virus Incubation Period: 30 – 50 days Incubation Period: 30 – 50 days Clinical Features:fever,tonsillopharngitis.cx lymphadenopathy,rash. Clinical Features:fever,tonsillopharngitis.cx lymphadenopathy,rash. Complications: Complications: Hepatitis Hepatitis Hemolytic Anemia Hemolytic Anemia GBS GBS Splenic rapture Splenic rapture Myocarditis Myocarditis Malignacy Malignacy Treatment Treatment

COMMON BACTERIAL INFECTIONS Staphyloccoacl and Group A streptoccocal infections. By direct effect –abscess,celluitis,imptigo,orbital celluitis. Toxin mediated:toxic shock syndrome Toxic epidermial necrolysis.

Continue…. Group A streptococcus: Direct effect.tonsillitis,osteomyelitis,om,celluitis Toxin mediated:toxic shock like syndrom,scarlet fever Post infectious.rheumatic fever,glomerulonephritis.

Haemophilus influenzae type b (Hib) Clinical Features Clinical Features Complications Complications Treatment Treatment Isolation & Infectivity: droplet precautions for 24 hours after starting antimicrobial therapy Isolation & Infectivity: droplet precautions for 24 hours after starting antimicrobial therapy Vaccine Vaccine Cerebrospinal fluid culture positive for Hib (Gram stain)

Hib (Cont.)

Pertusis (Whooping Cough) Bordetella Pertusis Bordetella Pertusis Incubation Period: 7 – 14 days Incubation Period: 7 – 14 days Clinical Features Clinical Features Complications: Complications: Pneumonia & Bronchiectasis Pneumonia & Bronchiectasis Haemorrhage Haemorrhage Hernia Hernia Hypoxia Hypoxia Treatment Treatment Isolation & Infectivity: up to 6 weeks, but with treatment => 5 days after starting therapy Isolation & Infectivity: up to 6 weeks, but with treatment => 5 days after starting therapy Vaccine Vaccine

Diagnosis Isolation by culture Isolation by culture Media: Regan-Lowe, Bordet-Gengou, or charcoal agar Media: Regan-Lowe, Bordet-Gengou, or charcoal agar Polymerase Chain Reaction PCR Polymerase Chain Reaction PCR Kids & Children Kids & Children Direct fluorescent antibody (DFA) Direct fluorescent antibody (DFA) NO Freezer or Refrigeration of samples NO Freezer or Refrigeration of samples

Route of Transmission Spread through direct contact of respiratory secretions. Spread through direct contact of respiratory secretions. Most contagious during first few stages of infection Most contagious during first few stages of infection Resides in upper airway pathways, mostly the trachea and bronchi. Resides in upper airway pathways, mostly the trachea and bronchi. Very contagious Very contagious

Progession of Whooping Cough Incubation period 4-21 days Incubation period 4-21 days 3 Stages 3 Stages 1 st Stage- Catarrhal Stage 1-2 weeks 1 st Stage- Catarrhal Stage 1-2 weeks runny nose, sneezing, low fever, and a mild cough (common mistaken for cold) runny nose, sneezing, low fever, and a mild cough (common mistaken for cold) 2 nd Stage- Paroxysmal Stage 1-6 weeks 2 nd Stage- Paroxysmal Stage 1-6 weeks whooping cough, which consists of bursts or paroxysms of numerous, rapid coughs, severity of the infection is at its greatest whooping cough, which consists of bursts or paroxysms of numerous, rapid coughs, severity of the infection is at its greatest 3 rd Stage- Covalescent Stage weeks-months 3 rd Stage- Covalescent Stage weeks-months gradual recovery starts gradual recovery starts

Complications Children Hypoxia Apnea Pneumonia Seizures Adults Pneumonia Rib Fracture Weight Loss Hernias Urinary Incontinence

Treatment Antibiotic Therapy Antibiotic Therapy Erythromycin Erythromycin Azithromycin Azithromycin Clarithromycin Clarithromycin

Prevention CDC recoomends children be given the Diphtheria, Tetanus, and Pertussis (DTaP) vaccine as early as 6 weeks but no later than 6 y/o. Good hygiene Cover mouth/nose when coughing and sneezing.

Diphtheria Corynebacterium diphtheriae Corynebacterium diphtheriae Incubation Period: 2 – 7 days Incubation Period: 2 – 7 days Clinical Features Clinical Features Complications: Complications: Thrombocytopenia Thrombocytopenia Myocarditis Myocarditis Vocal cord paralyses Vocal cord paralyses Treatment Treatment Isolation & Infectivity: up to 6 weeks, but with treatment communicable for fewer than 4 days Isolation & Infectivity: up to 6 weeks, but with treatment communicable for fewer than 4 days Vaccine Vaccine

Diphtheria is an upper respiratory tract illness caused by Corynebacterium diphtheriae, a facultative anaerobic, Gram- positive bacterium.respiratory Corynebacterium diphtheriaefacultative anaerobicGram- positivebacterium It is characterized by sore throat, low fever, and an adherent membrane (a pseudomembrane) on the tonsils, pharynx, and/or nasal cavity.fevertonsils pharynx

Case classification Probable: a clinically compatible case that is not laboratory-confirmed and is not epidemiologically linked to a laboratory-confirmed case Confirmed: a clinically compatible case that is either laboratory-confirmed or epidemiologically linked to a laboratory-confirmed case Empirical treatment should generally be started in a patient in whom suspicion of diphtheria is high.

Antibiotics are used in patients or carriers to eradicate C. diphtheriae and prevent its transmission to others. The CDC recommends either: Metronidazole ErythromycinErythromycin (orally or by injection) for 14 days (40 mg/kg per day with a maximum of 2 g/d), or Procaine penicillin GProcaine penicillin G given intramuscularly for 14 days (300,000 U/d for patients weighing 10 kg). - Patients with allergies to penicillin G or erythromycin can use rifampin or clindamycin.rifampinclindamycin

Diphtheria (Cont.) Diphtheria (Cont.)

Tetanus Clostridium tetani Clostridium tetani Incubation Period: 2 days to months, most within 14 days Incubation Period: 2 days to months, most within 14 days Clinical Features Clinical Features Complications: Complications: Lock jaw Lock jaw Neonatal mortality Neonatal mortality Generalized muscle spasm Generalized muscle spasm Treatment Treatment Isolation: no person to person transmission Isolation: no person to person transmission Vaccines Vaccines

Tetanus. -medical condition characterized by a prolonged contraction of skeletal muscle fibers.skeletal muscle -The primary symptoms are caused by tetanospasmin, a neurotoxin produced by the Gram-positive, rod-shaped, obligate anaerobic bacterium Clostridium tetani.tetanospasmin neurotoxinGram-positiverod-shaped obligate anaerobic bacteriumClostridium tetani - Infection generally occurs through wound contamination and often involves a cut or deep puncture wound. As the infection progresses, muscle spasms develop in the jaw (thus the name "lockjaw") and elsewhere in the bodyspasms

The wound must be cleaned. Dead and infected tissue should be removed by surgical debridement. Administration of the antibiotic metronidazole decreases the number of bacteria but has no effect on the bacterial toxin.debridementmetronidazolebacteria Penicillin was once used to treat tetanus, but is no longer the treatment of choice, owing to a theoretical risk of increased spasms.Penicillin

Guide to Tetanus Prophylaxis in Routine Wound Management History of Adsorbed Tetanus Toxoid (Doses) Clean, Minor WoundAll Other Wounds* TdTIGTdTIG Unknown or <3YesNoYesyes ≥3§No"NoNo¶No " yes if more than 10 years since last dose ¶ yes if more than 5 years since last dose

Tetanus can be prevented by vaccination with tetanus toxoid..vaccinationtetanus toxoid The CDC recommends that adults receive a booster vaccine every ten years, and standard care practice in many places is to give the booster to any patient with a puncture wound who is uncertain of when he or she was last vaccinated, or if he or she has had fewer than three lifetime doses of the vaccineCDCbooster

Thrush Candida Albicans Candida Albicans Clinical Features Clinical Features Complications Complications Treatment Treatment

Kawasaki disease Affect infant and young children Clinical criteria Fever >5days Conjunctival injection Red mucous membrane Cervical lymphadenopathy Rash Oedema of palms & soles with peeling

Further Reading RED BOOK by Report of the committee on Infectious Diseases. RED BOOK by Report of the committee on Infectious Diseases.

Viral Hepatitis

Feature Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E VirusHAVHBVHCVHDVHEV GenomeRNADNARNARNARNA Incubation days days 7-9 weeks 2-8 weeks days OnsetAcuteInsidiousInsidiousAcuteAcute TransmissionOralParenteralPerinatalParenteralParenteralOral Sequelae: Fulminant liver failure Carrier Chronic hepatitis RareNoNoUncommonYesYesUncommonYesYesYesYesYesYesNoNo Mortality % % 1-2 % 2-20 % 1-2 %