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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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viral hepatitis
Viral Hepatitis

Dr. Salwa Tayel

Associate Professor

Family and Community Medicine Department

King Saud University

21/2/2010

Dr. Salwa Tayel

2

slide3

Enterically

transmitted

“Infectious”

A

E

Viral hepatitis

“NANB”

C

Parenterally

transmitted

B

D

“Serum”

other

Viral Hepatitis – Historical Perspective

Dr. Salwa Tayel

slide4

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

acute hepatitis clinical symptoms
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

slide6

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

slide7

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

slide9

Cycle of infection

Agent

Susceptible Host

Reservoir

IP

PC

Portal of Inlet

Portal of Exit

Mode of transmission

Dr. Salwa Tayel

slide10

Infectious agent:

  • Hepatitis A Virus
  • Picornavirus (RNA)
  • Stable at low pH
  • Inactivated by high temperature, formalin, chlorine

Dr. Salwa Tayel

slide11

Reservoir:

  • Human
    • clinical
    • sub-clinical cases
    • incubating carriers

Outlet:

Through anal orifice with faeces.

Dr. Salwa Tayel

slide12

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

slide13

Through the mouth.

Inlet:

Susceptibility and resistance:

  • Susceptibility is general.
  • Post infection immunity after the attack probably lasts for life.

Dr. Salwa Tayel

slide14

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

prevention of hepatitis a
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

slide16

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

hepatitis a vaccine
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

slide18

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

viral hepatitis b hbv
Viral Hepatitis B (HBV)

21/2/2010

Dr. Salwa Tayel

21

slide21

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

slide22

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

slide23

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

slide25

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

chronic hepatitis b virus infection
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

slide27

HBsAg Prevalence

³8% - High

2-7% - Intermediate

<2% - Low

Geographic Distribution of Chronic HBV Infection

Dr. Salwa Tayel

slide28

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

slide29

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

slide30

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

slide31

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

slide32

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

slide33

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

slide34

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

slide35

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

slide36

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

indication of hepatitis b vaccination
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

prevention of perinatal hbv transmission
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

slide40

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

slide41

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

slide42

Viral hepatitis D

(HDV)

Dr. Salwa Tayel

hepatitis d delta virus

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

slide44

Taiwan

Pacific Islands

HDV Prevalence

High

Intermediate

Low

Very Low

No Data

Geographic Distribution of HDV Infection

Dr. Salwa Tayel

slide45

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

slide46

Hepatitis D Virus

Modes of Transmission

  • Percutanous exposures
    • injecting drug use
  • Permucosal exposures
    • sex contact

Dr. Salwa Tayel

slide47

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

slide48

Viral hepatitis C

(HCV)

Dr. Salwa Tayel

slide50

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

natural history of hcv infection

100 People

Time

15%

85%

Resolve(15)

Chronic(85)

80%

20%

Stable (68)

Cirrhosis (17)

75%

25%

Stable(13)

Mortality (4)

Leading Indication for Liver Transplant

Natural History of HCV Infection

Dr. Salwa Tayel

chronic hepatitis c factors promoting progression or severity
Chronic Hepatitis C Factors Promoting Progression or Severity
  • Increased alcohol intake
  • Age > 40 years at time of infection
  • HIV co-infection
  • Others:
    • Male gender
    • Chronic HBV co-infection

Dr. Salwa Tayel

slide53

Risk Factors Associated with

Transmission of HCV

  • Illegal injection drug use
  • Transfusion or transplant from infected donor
  • Occupational exposure to blood
    • Mostly needle sticks
  • Iatrogenic (unsafe injections)
  • Birth to HCV-infected mother
  • Sexual/household exposure to anti-HCV positive contact
  • Multiple sex partners

Dr. Salwa Tayel

sources of infection for persons with hepatitis c
Sources of Infection forPersons With Hepatitis C

Injecting drug use 60%

Sexual 15%

Transfusion 10%

(before screening)

Occupational 4%

Other 1%*

Unknown 10%

* Nosocomial; iatrogenic; perinatal

Dr. Salwa Tayel

Source: Centers for Disease Control and Prevention

slide55

Other modes of transmission:

  • percutaneous procedures using inadequately sterilized equipment (e.g. ear and body piercing, circumcision, tattooing)
  • HCV do not spread by sneezing, hugging, coughing, food or water, sharing eating utensils, or casual contact

Dr. Salwa Tayel

slide56
Prevention of HCV transmission- Reduce or Eliminate Risks for Acquiring HCV Infection- Preventing HCV Transmission from patients to Others- HCV testing/ screening

Dr. Salwa Tayel

slide57

Prevention of HCV transmission

  • Screening and testing donors of blood, organs, and tissues
  • Virus inactivation of plasma-derived products
  • Risk-reduction counseling and services
    • Obtain history of high-risk drug and sex behaviors
    • Provide information on minimizing risky behavior, including referral to other services
  • Infection control practices
  • Blood and body fluid precautions

Dr. Salwa Tayel

slide58

Public Health Service Guidelines for

Anti-HCV-Positive Persons

  • Anti-HCV-positive persons should:
  • Be considered potentially infectious
  • Keep cuts and skin lesions covered
  • Be informed of the potential for sexual transmission
  • Be informed of the potential for perinatal transmission
    • no evidence to advise against pregnancy or breastfeeding
  • Anti-HCV-positive persons should not:
  • Donate blood, organs, tissue, or semen
  • Share household articles (e.g., toothbrushes, razors)

Dr. Salwa Tayel

the end
The End

Thank You

Website http://faculty.ksu.edu.sa/73234/default.aspx

salwatayel@hotmail.com

Dr. Salwa Tayel