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Viral Hepatitis

Viral Hepatitis. Dr. Salwa Tayel. Associate Professor Family and Community Medicine Department King Saud University. 21/2/2010. 2. Enterically transmitted. “Infectious”. A. E. Viral hepatitis. “NANB”. C. Parenterally transmitted. B. D. “Serum”. other.

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Viral Hepatitis

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  1. Dr. Salwa Tayel

  2. Viral Hepatitis Dr. Salwa Tayel Associate Professor Family and Community Medicine Department King Saud University 21/2/2010 Dr. Salwa Tayel 2

  3. Enterically transmitted “Infectious” A E Viral hepatitis “NANB” C Parenterally transmitted B D “Serum” other Viral Hepatitis – Historical Perspective Dr. Salwa Tayel

  4. A, B, Cs of Viral Hepatitis • A • fecal-oral spread: hygiene, drug use, men having sex with men, travelers, day care, food • vaccine-preventable • B • sexually transmitted – 100x more infectious than HIV • blood-borne (sex, injection drug use, mother-child, and health care) • vaccine-preventable • C • blood borne (injection drug use primarily) • 4-5 times more common than HIV • NOT vaccine-preventable! Dr. Salwa Tayel

  5. Acute Hepatitis – Clinical Symptoms Asymptomatic > Symptomatic > Fulminant Liver Failure > Death Symptoms (if present) are the same, regardless of cause (e.g., A, B, C, other viruses, toxins) • Nausea, vomiting • Abdominal pain • Loss of appetite • Fever • Diarrhea • Light (clay) colored stools • Dark urine • Jaundice (yellowing of eyes, skin) Dr. Salwa Tayel

  6. Viral hepatitis A Infectious hepatitis, epidemic hepatitis, epidemic jaundice. Identification: • Children are usually asymptomatic, adults symptomatic • Onset is usually sudden with fever followed within few days by jaundice. • Complete recovery is the rule (no chronicity). • The case-fatality rate among persons of all ages is approximately 0.3% • but is approximately 2% among persons > 40 years. Dr. Salwa Tayel

  7. Occurrence: • It is worldwide • In developing countries, it occurs in endemic and epidemic forms due to: • Poor environmental sanitation • Overcrowding • Lack of personal hygiene. Dr. Salwa Tayel

  8. Geographic Distribution of HAV Infection Dr. Salwa Tayel

  9. Cycle of infection Agent Susceptible Host Reservoir IP PC Portal of Inlet Portal of Exit Mode of transmission Dr. Salwa Tayel

  10. Infectious agent: • Hepatitis A Virus • Picornavirus (RNA) • Stable at low pH • Inactivated by high temperature, formalin, chlorine Dr. Salwa Tayel

  11. Reservoir: • Human • clinical • sub-clinical cases • incubating carriers Outlet: Through anal orifice with faeces. Dr. Salwa Tayel

  12. Mode of transmission: • Fecal-oral route. Close personal contact; house hold contact,, sex contact, day care centers. • Common vehicle; contaminated water and food; raw shellfish food handlers . • Rarely through blood transfusion and contaminated syringes. Dr. Salwa Tayel

  13. Through the mouth. Inlet: Susceptibility and resistance: • Susceptibility is general. • Post infection immunity after the attack probably lasts for life. Dr. Salwa Tayel

  14. Incubation period: • Incubation period 28 days (range 15-50 days) Period of communicability: • The maximum infectivity is during the latter half of the incubation period (2 weeks before and 1 week after onset of jaundice). Dr. Salwa Tayel

  15. Prevention of Hepatitis A • Vaccination • Immune globulin • Good hygiene (hand washing) • Clean water systems; avoidance of food contamination • Food sanitation especially shell fish and raw eaten food. Dr. Salwa Tayel

  16. Hepatitis A Prevention – Immune Globulin • Pre-exposure • travelers to intermediate and high HAV-endemic regions • Post-exposure (within 14 days) Routine • household and other intimate contacts Selected situations • institutions (e.g., day care centers) • common source exposure (e.g., food prepared by infected food handler) Dr. Salwa Tayel

  17. Hepatitis A Vaccine • Inactivated whole virus vaccine. • Licensed for persons 1 year of age and older. • Schedule 2 doses • First dose then booster dose 6-18 months after first. • Gives protection after 4 weeks of the fist dose. • The vaccine should be administered intramuscularly. • Site: deltoid muscle. Dr. Salwa Tayel

  18. Indications of Hepatitis A Vaccine • Persons at increased risk for infection: • travelers to intermediate and high HAV-endemic countries (Individuals who will travel to high‑risk areas <4 weeks after the initial dose of vaccine should also be given IG) • MSM (Men who have sex with men) • illegal drug users • Persons who have clotting factor disorders • persons with chronic liver disease • For communities with historically high rates of hepatitis A: -routine childhood vaccination Dr. Salwa Tayel

  19. Dr. Salwa Tayel

  20. Viral Hepatitis B (HBV) 21/2/2010 Dr. Salwa Tayel 21

  21. Viral hepatitis B (HBV) Serum hepatitis, serum jaundice. Identification: • Clinical signs & symptoms occur more in adults. • At least 50% of infections are asymptomatic • Onset is usually gradual with anorexia, nausea and vomiting, often progressing to jaundice. Dr. Salwa Tayel

  22. Hepatitis B – Clinical Features • Incubation period:Average 60-90 days • Range 45-180 days • Clinical illness age <5 yrs, <10%(jaundice):>5 yrs, 30%-50% • Acute case-fatality rate:0.5%-1% • Chronic infection:<5 yrs, 30%-90%>5 yrs, 2%-10% • Premature mortality fromchronic liver disease:15%-25% Dr. Salwa Tayel

  23. Symptomatic Infection of Hepatitis B Virus by Age at Infection 100 80 60 Symptomatic Infection (%) 40 20 Symptomatic Infection 0 Birth 1-4 yrs 1-6 mos 7-12 mos Older Children and Adults Dr. Salwa Tayel

  24. Risk of Chronic HBV Carriage by Age of Infection Dr. Salwa Tayel

  25. 100 100 80 80 60 60 Chronic Infection 40 40 20 20 Symptomatic Infection 0 0 Birth 1-4 yrs 1-6 mos 7-12 mos Older Children and Adults Outcome of Hepatitis B Virus Infection by Age at Infection Chronic Infection (%) Symptomatic Infection (%) Dr. Salwa Tayel

  26. CHRONICHepatitis B Virus Infection • Overall risk: 10% of all acute infections. • About 15%-25% of persons with chronic HBV infection might die from either cirrhosis or liver cancer • Chronic infection occurs in: • ~ 90% of infants infected with HBV at birth • ~ 30% of children infected at age 1- 5 years • 2- 6% of people infected after age 5 years Dr. Salwa Tayel

  27. HBsAg Prevalence ³8% - High 2-7% - Intermediate <2% - Low Geographic Distribution of Chronic HBV Infection Dr. Salwa Tayel

  28. Global Patterns of Chronic HBV Infection • High (>8%): • 45% of global population • early childhood infections common • Intermediate (2%-7%): • 43% of global population • infections occur in all age groups • Low (<2%): • 12% of global population • most infections occur in adult risk groups Dr. Salwa Tayel

  29. Cycle of infection Agent Susceptible Host Reservoir IP PC Portal of Inlet Portal of Exit Mode of transmission Dr. Salwa Tayel Dr. Salwa Tayel 31

  30. Double-Stranded DNA HBsAg HBcAg HBeAg Hepatitis B Virus HBsAg • The presence of HBsAg indicates active infection or chronic carrier. • Antibody to HBsAg, from either disease or vaccine, indicates immunity. Dr. Salwa Tayel

  31. Reservoir: Human (cases and carriers). Source: • Human blood and blood products can transmit infection if not screened for HBs Ag. • Other body Fluids have the virus with varying concentrations. Dr. Salwa Tayel

  32. Low/Not High Moderate Detectable blood semen urine serum vaginal fluid feces wound exudates saliva sweat tears breast milk Concentration of HBV in Various Body Fluids Dr. Salwa Tayel

  33. Mode of transmission: • Parenteral: Unsafe injections and transfusions, organ transplants, sharing needles, haemodialysis, needle sticks, tattooing , razors and toothbrushes. • Perinatal exposure, especially when HBs Ag carrier mothers are also HBe Ag positive. • Sexual exposure. Dr. Salwa Tayel

  34. Incubation period: From 45-180 days, average 60-90 days. Period of communicability: • 1-2 months before the onset of symptoms • during acute clinical course • during the chronic carrier state which may persist for life. Dr. Salwa Tayel

  35. Elimination of HBV Transmission Strategy • Prevent perinatal HBV transmission • Routine vaccination of all infants • Vaccination of children in high-risk groups • Vaccination of adolescents & all children up through age 18 • Vaccination of adults in high-risk groups Dr. Salwa Tayel

  36. Hepatitis B Vaccine • Currently, subunit recombinant HBs Ag • given IM in the deltoid region. • 3 dose series, typical schedule 0, 1-2, 4-6 months - no maximum time between doses (no need to repeat missed doses or restart) • Protection • ~30-50% dose 1 • 75% - dose 2 • 96% - dose 3 • lower protection in older, immunosuppressive illnesses (e.g., HIV, chronic liver diseases, diabetes), obese, smokers Dr. Salwa Tayel

  37. Indication of Hepatitis B Vaccination • Routine for infants. • Ages 11-15 “catch up”, and through age 18 years • Over 18 – high risk • Occupational risk health care workers (HCWs) • Hemodialysis patients • All clinic clients of sexually transmitted diseases (STD) • Multiple sex partners or prior STD • MSM (Men having sex with men) • IDU (injecting drug users) • Institution for developmental disability (Staff & clients) Dr. Salwa Tayel

  38. Dr. Salwa Tayel

  39. Prevention of perinatal HBV transmission Prevent perinatal HBV transmission by: • screening all pregnant women for hepatitis B surface antigen (HBsAg) & • providing hepatitis B immune globulin (HBIG) in combination with hepatitis B vaccine to infants of HBsAg‑positive mothers Dr. Salwa Tayel

  40. Immunoglobulins(HBIG): (HBIG) is indicated in combination with the vaccine in: • accidental needle stick injury • sure sexual exposure • perinatal exposure In blood banks: • screening of blood donors • And avoid donors from risky group. Dr. Salwa Tayel

  41. Use of adequately sterilized syringes and needles or preferably use disposal equipment. • Discourage risky behaviors e.g. tattooing, drug abuse and extramarital relations. • Avoid transmission from persons with (e antigen), especially medical and dental personnel who routinely perform invasive procedures. • Health care personnel should follow the universal precautions. Dr. Salwa Tayel

  42. Viral hepatitis D (HDV) Dr. Salwa Tayel

  43. HBsAg d antigen RNA Hepatitis D (Delta) Virus HDV is a defective single‑stranded RNA virus (delta Ag) It requires HBV for synthesis of envelope protein composed of HBsAg. Dr. Salwa Tayel

  44. Taiwan Pacific Islands HDV Prevalence High Intermediate Low Very Low No Data Geographic Distribution of HDV Infection Dr. Salwa Tayel

  45. Hepatitis D - Clinical Features • Coinfection with HBV • severe acute disease • low risk of chronic infection • Superinfection on top of chronic HBV • usually develop chronic HDV infection • high risk of severe chronic liver disease Dr. Salwa Tayel

  46. Hepatitis D Virus Modes of Transmission • Percutanous exposures • injecting drug use • Permucosal exposures • sex contact Dr. Salwa Tayel

  47. Prevention of Hepatitis D • HBV-HDV Coinfection • Pre or postexposure prophylaxis to prevent HBV infection (HBIG and/or Hepatitis B vaccine) • HBV-HDV Superinfection • Education to reduce risk behaviors among persons with chronic HBV infection Dr. Salwa Tayel

  48. Viral hepatitis C (HCV) Dr. Salwa Tayel

  49. Prevalence of HCV Infection Among Blood Donors Dr. Salwa Tayel

  50. Hepatitis C – Clinical Features • Incubation period:Average 6 - 7 wks • Range 2 – 26 wks • Acute illness (jaundice)Mild (≤20%) • Case fatality rateLow • Chronic infection60%-85% • Chronic hepatitis 70% • Cirrhosis 5%-20% • Mortality from CLD :3% Dr. Salwa Tayel

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