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MANAGEMENT OF HEPATITS A

MANAGEMENT OF HEPATITS A . Dr Rajdeep Singh Department of Gastroenterology Fortis Hospital Mohali. Human Hepatitis Viruses. Virus Genome Genome Envelope Family / genus size (kb).

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MANAGEMENT OF HEPATITS A

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  1. MANAGEMENT OF HEPATITS A Dr Rajdeep Singh Department of Gastroenterology Fortis Hospital Mohali

  2. Human Hepatitis Viruses Virus Genome Genome Envelope Family / genus size (kb) HAV RNA 7.5 - Picornaviridae hepatovirus HBV DNA 3.2 + Hepadnaviridae HCV RNA 9.6 + Flaviviridae hepacivirus HDV RNA 1.7 + Unclassified (viroid), delta virus HEV RNA 7.5 - Unclassified, togavirus and alpha virus-like

  3. Nucleic Acid: 7.5 kb ssRNA • Classification: Picornaviridae, Hepatovirus • One serotype and multiple genotypes • Nonenveloped, acid and heat stable • In vitro model: monkey and human cell cultures • In vivo replication: in cytoplasm of hepatocyte; human and other higher primates 27 nm Hepatitis A Virus

  4. Hepatitis A Transmission • Fecal-oral route • Food handlers • Travel to endemic areas • Close personal contact • Household or sexual contact • Daycare centers • Blood-borne (rare) • Injecting drug users

  5. EPIDEMIOLOGY • Acute hepatitis A is a reportable infectious disease in the US • Different epidemiological patterns seen • In developing countries where sanitary conditions are poor, most children are affected at an early age • Majority of pre school children in these countries had anti-HAV in serum reflecting previous subclinical infection

  6. In developed countries, there is low prevalence of HAV infection among children and young adults • Universal HAV vaccination was adopted in 2005 in the US. Zhou F, Shefer A, Weinbaum C, et al: Impact of hepatitis A vaccination on health care utilization in the United States, 1996-2004. Vaccine 2007; 25:3581-7.(Ref 34.)

  7. EPIDEMIOLOGICAL SHIFT • Shift in the age of acquiring infection from childhood to older age groups • Peak age of seroprevalence is shifting from 1st decade of life to 2nd and 3rd decades • An increase in symptomatic cases and severe clinical outcomes including fulminant hepatic failure Indian J Med Res 128, December 2008, pp 699-704

  8. CASE • 37 year male presents with low grade fever for 7 days associated with nausea, vomiting, retching, headache. • H/O passage of deep yellow urine, yellow eyes for 3 days and now fever has subsided. No h/o BT, surgery, jaundice in past. • On examination he is icteric, no stigmata of CLD, mild tender hepatomegaly, no splenomegaly. • Investigated found to have TSB 5mg% with direct 4%, SGOT 3675, SGPT 4698 and ALP 250, INR 1.2. • USG abdomen shows hypoechoic mild hepatomegaly with diffuse thickening of GB wall, no free fluid or spleenomegaly

  9. DIAGNOSTIC APPROACH ACUTE HEPATITIS IgM Anti HEV HbsAg, Anti HCV Anti HEV + Anti HEV - Anti HEV - HbsAg ,Anti HCV neg HbsAg +, Anti HCV - HbsAg, Anti HCV - IgM Anti HBc + IgM Anti HAV + Acute hepatitis EAcute hepatitis B Acute hepatitis A Anti HDV+ Hepatitis D co infection

  10. DIAGNOSTIC APPROACH ACUTE HEPATITIS IgM Anti HAV, HEV - HbsAg, Anti HCV – IgM Anti HBc IgM Anti HBc + IgM Anti HBc - Acute hepatitis B Work up for other causes of hepatitis- drugs, Wilsons, CMV, HSV, EBV

  11. Spectrum of sporadic acute viral hepatitis in India Saigal Nundy Subrat Hepatitis E 29% 45% 38% Hepatitis B 23% 12.5% 7.3% Hepatitis A 12% 33% 17.5% Hepatitis C 0 0.8% 2.8% Saigal et al , Indian Jr of Gastroenterology, 2007 Nundy et al, Medical Jr of armed forces, 2009 Subrat et al, Hepatobiliary Pancreat Dis Int, 2007

  12. Spectrum of acute hepatitis in India • Viral hepatitis 64% • Drug induced 10% • Ischemic 2% • Acute fatty liver pregnancy 0.7% • Cryptogenic 23% Siagal S et al, Indian Journal of Gastroenterology , 2007

  13. Symptoms ALT Total anti-HAV Fecal HAV IgM anti-HAV 4 5 6 12 24 0 1 2 3 Months after exposure Typical Serologic Course of Acute Hepatitis A Virus Infection

  14. Clinical Variants of Hepatitis A Infection • Asymptomatic (anicteric) disease • Children under 6 years of age, > 90% • Children from 6-14 years old, 40-50% • Symptomatic (icteric) disease • Adults and children over 14, 70-80%

  15. Clinical Patterns of HAV Infection • Cholestatichepatitis • Relapsing hepatitis • Fulminant hepatic failure

  16. CHOLESTASIS • Can extend upto 8 weeks • Corticosteroids have been used • No conclusive evidence

  17. EXTRAHEPATIC MANIFESTATIONS • Evanescent rash 14% • Arthralgias 11% • Leukocytoclastic vasculitis • Glomerulonephritis • Arthritis

  18. RELAPSING HEPATITS A • 10% of patients with acute hepatitis A • Shedding of HAV in stool documented during the relapse phase • Benign • Infection ultimately resolves • No increase in mortality • Treatment is symptomatic

  19. SYMPTOMATIC TREATMENT • No specific antiviral drug available • Most patients do not require hospital care • Restricted physical activity • High calorie diet is desirable • Avoid hepatotoxic drugs • Simple hygienic precautions

  20. MYTHS • Strict bed rest • No fatty foods • No yellow foods • Sugarcane juice • Liv - 52

  21. HEPATITS A VACCINE • Licensed for use after 12 months of age • Only high risk populations targeted for immunization • HAVRIX by SmithKline • VAQTA by Merck • Derived from HAV grown in cell culture Centers for Disease Control and Prevention: Prevention of hepatitis A thorough active or passive immunization. MMWR 2006; 55(No. RR07):1-23.(Ref 25.)

  22. HEPATITIS A VACCINE • Safe & immunogenic • Long lasting immunity ~ 20 years In age 1-18 yrs • 0.5 ml ( 720 ELU ) at 0, 6-12 months In age >18 yrs • 1ml (1440 ELU ) at 0, 6-12 months Centers for Disease Control and Prevention: Prevention of hepatitis A thorough active or passive immunization. MMWR 2006; 55(No. RR07):1-23.(Ref 25.)

  23. Post Exposure Prophylaxis • Single dose HAV vaccine within 2 weeks of exposure • Long term immunity • Immunoglobulin was preferred earlier • Immediate & short term protection Centers of Disease Control and Prevention: Prevention of hepatitis A after exposure to hepatitis A virus and in international travelers. MMWR 2007; 56:1080-4.(Ref 54.)

  24. TWINRIX • Combined formulation of HAV & HBV vaccines • Approved by FDA for persons 18 yrs or older • 0,1,6 schedule At 1 year • HAV seroconversion 100% • HBV seroconversion 96.4 – 100% FDA approval for a combined hepatitis A and B vaccine. MMWR 2001; 50:806.(Ref 60.)

  25. IAP RECOMMENDATIONS FOR USE HAV Vaccine may be offered to all healthy children with special emphasis in risk groups IAP Guide book on Immunization 2011

  26. RISK GROUPS • Patients with chronic liver disease • Carriers of Hepatitis B and C • Congenital or acquired immunodeficiency • Transplant recipients • Adolescents seronegative for HAV and leaving for boarding schools • Travelers to high endemic areas for HAV • Household contacts of patients with acute Hepatitis A within 10 days.

  27. TAKE HOME POINTS • In India, most individuals acquire natural infection in childhood • HAV infection tends to be more symptomatic in adults • HAV infection is a self limiting illness • No specific antiviral drug is available • HAV vaccine provides long lasting immunity to individuals at risk

  28. THANK YOU

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