Hepatitis B Virus

1. Hepatitis B Virus

2. *-در آزمايشلت دوران حاملگي خانمي30 ساله HbsAg مثبت و Anti Hbc IgM منفیگزارش مي شود اين بيمار سراسيمه به شما مراجعه مي نمايد.به سوالات مطرح شده در ارتباط با اين بيمار پاسخ دهيد؟

3. 1- خطر ابتلاء به بيماريهاي مزمن كبدي و عواقب ناشي از آن براي اين بيمار حدوداً چقدر مي باشد الف ـ 15-5% ب ـ 25-15% ج ـ 65-35% د ـ 80-60%

5. Hepatitis B - Clinical Features • Incubation period: Average 60-90 days • Range 45-180 days • Acute case-fatality rate: 0.5%-1% • Premature mortality fromchronic liver disease: 15%-25%

6. 2-خطر مزمن شدن هپاتيتدر اين فرد در صورتيكه در زمان نوزادي يا بلوغ مبتلا به هپاتيت B شود به ترتيب چقدر مي باشد؟ • الف ) 5-10 %ـ 90 % • ب ) 25-30 % ـ 75 % • ج ) 90-95 % ـ 5-10 % • د ) 75 % ـ 25 %

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

8. Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Symptoms anti-HBe HBeAg Total anti-HBc Titer anti-HBs IgM anti-HBc HBsAg 0 4 8 12 16 24 28 32 52 100 20 36 Weeks after Exposure

9. Progression to Chronic Hepatitis B Virus Infection Typical Serologic Course Acute (6 months) Chronic (Years) HBeAg anti-HBe HBsAg Total anti-HBc Titer IgM anti-HBc Years 0 4 8 16 20 24 28 36 12 32 52 Weeks after Exposure

10. 3-ميزان آلودگي به هپاتيت B در كشور ما چقدرمي باشد ؟ الف ) 3-1.7% ب ) 1-0.5 % ج ) 8-5 % د ) 10 %

11. An estimated 350 million persons worldwide are chronically infected with HBV

12. The HBsAg carriers rate varies from 0.1 to 20 percent in different population in the world

13. Global Patterns of Chronic HBV Infection • High (³8%): 45% of global population • lifetime risk of infection >60% • early childhood infections common • Intermediate (2%-7%): 43% of global population • lifetime risk of infection 20%-60% • infections occur in all age groups • Low (<2%): 12% of global population • lifetime risk of infection <20% • most infections occur in adult risk groups

14. Geographic Distribution of Chronic HBV Infection HBsAg Prevalence ³8% - High 2-7% - Intermediate <2% - Low

15. 4- كداميك از موارد زير جزء معيارهاي ناقلين سالم هپاتيت B مي باشد؟ الف ـ ALT نرمال ب ـ HBV DNA < 105 copy/ml ج ـ HBe Ab (+) د ـ هر سه

16. Diagnostic Criteria:

17. Resolved Hepatitis B: 1- Previous known history of hepatitis or anti-HBC ± anti HBs 2- HBsAg - 3- Undetectable HBV DNA 4- Normal ALT

18. Inactive HBsAg Carrier State: - HBeAb+ - Normal ALT - Minimal or No Necroinflammation - Outcome is Benign - Serial tests should be performed before determined - 20% can have exacerbations: - ALT > 5 – 10 times - HBeAg± - Repeat can lead to progressive Fibrosis

19. Chronic Hepatitis B: 1- HBsAg+ > 6 m 2- HBV DNA > 10 5 3- Persistent or Intermittent ALT/AST 4- Liver Biopsy Score ≥ 4

20. 5- كداميك از حالات هاي زيرممکن است براي بيمار اتفاق افتد؟ الف ـ بهبود خود به خودي ب ـ سيروز ج ـ HCC د ـ هر سه

21. Outcome of Inactive HBsAg Carriers: • -Generally Benign • Exacerbation of hepatitis to 20% (as evidenced by  Alt ) • Seroconversion of HBsAg to Anti HBs (0.5-1%per year) • Progression to cirrhosis or HCC

22. Liver Cirrhosis • The most common aetiology of liver cirrhosis in Iran is HBV ,the second problem is higher chronically rate in those who acquired HBV in Perinatal period or early childhood and unfortunately screening of HBsAg in all of pregnant is not an obligatory.

23. Outcome of Cirrhosis - HBeAg+ 72% - Compensated –84% at 5y - HBeAg- 97% - 68% at 10 y - De-Compensated – 14% at 10y Risk Factors for De-compensation: - HBeAg+ - Failure to Respond to Interferon

24. HCC HBV is the most common aetiology of hepatocellular carcinoma (72% of HCC patients have HBcAb , 46% of them are HBsAg positive) .

25. 6- براي تشخيص هپاتوسلولاركارسينوما (HCC) در فرد مبتلا به هپاتيتBكداميك از متدهاي زير مناسب است ؟ الف ) FP ب ) GT ج ) U.S (سونوگرافي) د ) الف و ج

26. Periodil: Screening for HCC

27. AFPr Testing

28. Normal is Less than 8-12 ng/ml - Sensitivity for Small HCC, 50-75% - Specificity is Above 90% - Negative Predictive Value > 99% - Positive Predictive Value is: 9-30%

29. US is the only radiographic test that has been prospectively studied as an imaging tool for HCC surveillance. the sensitivity for small HCC ranged from 68% to 87% and false-positive rate from 28% to 82%. Regenerating nodules, seen In patients with cirrhosis, are the most common reason for false-positive results. US is considerably more expensive thanAFP.

30. Carriers of any age, even Asymptotic Persons with Normal ALT and Minimal or Absent Liver Disease, Can Develop HCC

31. Evaluation of patients with chronic HBV infection

33. CBC,Plt Liver function tests : Ast Alt,Alkp,GGt Bili(T,D)PT,PTT Total protein Albumin Globulin -a1 -a2 -b -g FBS-chol-TG HBsAg,HBsAb,HBeAg,HBeAb,HBcAb Laboratory Tests

34. In High Risk Patients • HIV Ab • HCV Ab • HDV Ab

35. 1-Hepatits B panel HBsAg-HBeAg-HBeAb - HBcAb- HBsAb i Confirmation of HBsAg(+) i Filing

36. Abdominal Sonography Liver-Spleen-Diameter of Portal vein Liver Biopsy • Grading • Staging

37. Follow-up for Patients Not Considered for Treatment

38. 1-InActive HBsAg Carrier State - ALT Every 6-12 months - If ALT > 1-2 x U.L.N, Check HBV DNA and Exclude Other Causes of Liver Disease - Screening for HCC

39. 2- HBeAg+, HBV DNA>105, Normal ALT - ALT Every 3-6 months - If ALT > 1-2 uln, Every 1-3 m. - If ALT>2, for 3-6 m., Consider Liver Biopsy and Treatment - Screening for HCC

40. Counseling and Prevention of Hepatitis B

41. HBV is transmitted by Perinatal, Percutaneous, Sexual Exposure, and Close person-to-person contact(presumably by open cuts and sores, especially among children in hyperendemic areas)

42. 7- كداميك از موارد زير بيماري را بيشتر منتقل مي نمايد؟ الف ـ ترشحات زخم ب ـ بزاق ج ـ شير مادر د ـ ترشحات واژينال

43. Concentration of Hepatitis B Virus in Various Body Fluids Low/Not High Moderate Detectable blood semen urine serum vaginal fluid feces wound exudates saliva sweat tears breastmilk

44. 8- كداميك از توصيه هاي زير براي پيشگيري از انتقال بيماري به اطرافيان مورد قبول شماست؟ الف ـ جدا كردن ظرف غذا خوري و قاشق و چنگال ب ـ عدم دست دادن و بوسيدن فرد بيمار ج ـ عدم شنا در استخر يااستفاده از وان حمامي كه بيمار قبلا از آن استفاده كرده است. دـ هيچكدام

45. Elimination of Hepatitis B Virus Transmission United States Strategy • Prevent perinatal HBV transmission • Routine vaccination of all infants • Vaccination of children in high-risk groups • Vaccination of adolescents • all unvaccinated children at 11-12 years of age • “high-risk” adolescents at all ages • Vaccination of adults in high-risk groups

46. Steady sexual partners should be tested and vaccinated against hepatitis B if found to be seronegative. For casual sex partners or steady partners who have not been tested or have not completed the full immuniza­tion series, barrier protection methods should be employed.

47. 8) رژيم غذايي بيمار چگونه بايد باشد؟ الف ـ عدم مصرف تخم مرغ ب ـ عدم مصرف گوشت قرمز ج ـ عدم مصرف چربي د ـ هيچكدام

48. Non-Specific Dietary Unless Use • of Alcohol > 40 g/d

49. Pregnant Women HBsAg+ should be Counseled:

50. 9- خطر انتقال بيماري به نوزادش در صورتيكه مادر HBe Ag+ باشد چقدر است؟ الف ـ بيش از 90% ب ـ 80-60% ج ـ 55-35% د ـ 15-5%