Hepatitis B And Post Exposure Prophylaxis Dr. Gagandeep Goyal

1. Hepatitis B And Post Exposure Prophylaxis Dr. GagandeepGoyal

2. Hepatitis • Inflammation of the liver, which may be caused by a viral infection, poisons, or the use of alcohol or other drugs • Types of Viral Hepatitis: Hepatitis A, B, C, D, E, G • Outcomes range from acute flu-like illness to jaundice, extreme fatigue and nausea to advanced hospitalization to death • Types of Viral blood-borne Hepatitis: Hepatitis B, C, D, G • Types of Viral Feaco-oral Route: Hepatitis A, E

3. INTRODUCTION • Hepatitis B is a Vaccine-preventable Communicable disease • Transmitted through sexual contact, direct blood exposures (percutaneous, non-intact skin, and mucous membrane), human bites that break the skin and cause bleeding, perinatally, among household contacts of carriers

4. The risk of developing chronic HBV infection after acute exposure ranges • 90% in newborns of HBeAg-positive mothers • 25% to 30% in infants and children under 5 and to Less than 5% in adults.

5. Problem Statement • Hepatitis B is endemic in almost all part of world • 60% of world population live in endemic area • Estimated 2 billion people infected • 360 million live with chronic infection • 600,000 person dies annually as result of consequence of hepatitis B every year • Estimated 25% child dies in later life as a consequence of hepatitis B infection

6. Natural History of Hepatitis B Virus (HBV) Infection

7. DEFINITIONS Occupational exposure refers to exposure to potential blood-borne infections (HIV, HBV and HCV) during performance of duties. Non-occupational exposure refers to exposure to potential blood-borne infections (HIV, HBV, HCV) outside work setting- e.g. sexual assault /rape etc Post exposure prophylaxis (PEP) refers to the comprehensive management given to minimize the risk of infection following potential exposure to blood-borne pathogens (HIV, HBV, HCV) 7

8. EMPLOYEES POTENTIALLY AT RISK • Physicians and Surgeons • Nurses • Phlebotomists • Medical Examiners • Dentists and Dental Workers • Some Laundry and housekeeping Employees • Clinical/Diagnostic Laboratory Workers • Medical Technologists • Nursing Home Personnel • Dialysis Personnel

9. Risk of HBV, HCV and HIV Transmission after Occupational Percutaneous Exposure • HBV risk varies depending on e-antigen status of source person • If e-antigen positive, risk is up to 30% • If e-antigen negative, risk is 1-6% • HCV risk is 1.8% (range of 0 - 7%) • HIV risk is 0.3% (range of 0.2 - 0.5%)

10. Occupational Blood-Borne ExposuresRelative Risk of Sero-conversion with Percutaneous Injury .

11. WORK PRACTICES WHICH INCREASE THE RISK OF NEEDLE STICK INJURY Recapping needles (Most important). Performing activities involving needles and sharps in a hurry. Handling and passing needles or sharp after use. Failing to dispose of used needles properly in puncture-resistant sharps containers. Poor healthcare waste management practices. Ignoring Universal Work Precautions.

13. POST EXPOSURE PROPHYLAXIS (PEP) It refers to the comprehensive management to minimize the risk of infection following potential exposure to blood borne pathogens (HIV, HBV, and HCV).

14. REMEMBER Exposure with discarded sharps/needles, contaminated for over 48hrs, the risk for HIV is negligible but risk for HBV remains significant as HBV survives longer outside the body.

15. Exposure: • Significant Exposure: • The event of percutaneous exposure such as sharp injuries. • Mucocutaneous injuries such as exposure through breeched skin. • Non Significant Exposure: • Blood splashes • Exposure to urine • Faeces • Saliva • Exposure to non contaminated sharp objects

16. Elements of Post exposure Management: HBV • Baseline evaluation and testing of exposed person with unknown HBV immune status. • Consideration of treatment • When to give • What to give • Follow up testing and counselling

17. Post exposure Management: Baseline HBV testing of Exposed Person • Test for anti-HBs if the person has been vaccinated, but vaccine response is unknown. • Baseline testing not necessary if the vaccine response is known. • If exposed person has been vaccinated and is a known responder to vaccine, no PEP is necessary.

18. WOUND CARE • Clean wounds with soap and water. • Do not squeeze. • Flush mucous membranes with water. • Avoid use of bleach and other agents caustic to skin.

20. EFFICACY OF HBV PEP Regimen Prevention of HBV infection • Multiple doses of HBIG alone when 1st dose initiated within in one week • Hepatitis B vaccine series alone • Combination of HBIG and vaccine series • 70-75% • 70-75% • 85-95%

21. HEPATITIS B VACCINE The vaccine consist of a series of 3 doses via IM injection into the deltoid muscle of the arm. • Dose # 1 is time zero • Dose # 2 given one month after dose #1 • Dose # 3 is given 6 months after dose #1

22. HEPATITIS B • Antibody (titer) level determines effectiveness. • Titer level 10 or less - entire series needs repeating(all 3 doses) • After the second series, titer less than 10, the person is considered to be a “primary non-responder” • Non-responder will need the HBIG if a contaminated puncture/body fluid exposure.

23. Hepatitis B Vaccine: Long Term Efficacy • Anti-HBs titers decline to <10 mIU/mL in 30-50% of adults within 8-10 years after vaccination. • Immune memory remains intact for at least 20 years after immunization. • Chronic HBV infection rarely documented among vaccine responders. • Routine booster doses are NOT routinely recommended for any group.

24. Side effects of Hepatitis B Vaccine • Pain at injection site. • Mild to moderate fever. • Anaphylaxis in an estimated 1 in 600,00o doses given. • No serious adverse event detected through surveillance. • No risk of adverse effects to fetus.

25. Post Exposure Management:Follow-up HBV testing of exposed person • Perform follow-up anti-HBs testing in healthcare personnel who receive Hepatitis B vaccine • Test for anti-HBs 1-2 months after last dose

26. Recommendations Hepatitis B Vaccine Offer vaccination to all personnel who are at risk of exposure to blood

27. UNIVERSAL PRECAUTIONS • Wearing gloves when touching blood, all body fluids including all secretions and excretions (with the exception of sweat), and contaminated items • A mask, gown, and eye protection or a face shield activities that are likely to generate splashes and sprays of blood, body fluids, secretions, and excretions • Double gloving for high risk surgical/obstetrical procedures, • Blunted suture needles, and , needleless connectors and infusion sets, and enhanced education

28. HEPATITIS B VACCINE • Neonates of HBsAg positive mothers • Other high-risk groups • Sexually active individuals with multiple sex partners and homosexual or bisexual • Household contacts of patients with hepatitis B • Intravenous drug users • Healthcare workers • Patients on chronic hemodialysis • Patients with chronic liver disease • All unvaccinated persons traveling to areas with intermediate to high levels of endemic HBV • Patients with diabetes

29. Carry Home Message • Universal precautions • Vaccinate high risk individuals • Once exposes, PEP with vaccine and HBIG • Checking antiHbsAg levels in health care workers • Treating vaccine non responders