Hepatitis and Management

2. Hepatitis

3. Hepatitis
inflammation of the liver
• Can have many causes
– drugs
– toxins
– alcohol
– viral infections (A, B, C, D, E)
– other infections (parasites, bacteria)
– physical damage

5. Liver
• Functions
– Stores sugar needed for energy
– Absorbs good nutrients
– Breaks down poisons (toxins) and drugs
– Makes important proteins that help build new
tissue and repair broken tissue
– Produces bile, which helps remove waste from
the body

6. Hepatitis Terms
• Acute Hepatitis: Short-term hepatitis.
– Body’s immune system clears the virus from
the body within 6 months
• Chronic Hepatitis: Long-term hepatitis.
– Infection lasts longer than 6 months because
the body’s immune system cannot clear the
virus from the body

7. Source of
virus
feces blood/
blood-derived
body fluids
blood/
blood-derived
body fluids
blood/
blood-derived
body fluids
feces
Route of
transmission
fecal-oral percutaneous
permucosal
percutaneous
permucosal
percutaneous
permucosal
fecal-oral
Chronic
infection
no yes yes yes no
Prevention pre/post-
exposure
immunization
pre/post-
exposure
immunization
blood donor
screening;
risk behavior
modification
pre/post-
exposure
immunization;
risk behavior
modification
ensure safe
drinking
water
Type of Hepatitis
A B C D E

8. Hepatitis A
Infection of the liver caused by Hepatitis A
virus

9. Hepatitis A Virus

10. Geographic Distribution of HAV
Infection
Anti-HAV Prevalence
High
Intermediate
Low
Very Low

11. Hepatitis A
• Incubation period
– 30 days on average (range 15-50 days)
– infectious latter half of incubation period while
asymptomatic through 1 week after having
jaundice.

12. Hepatitis A
– Nausea
– Loss of appetite
– Vomiting
– Fatigue
– Fever
– Dark urine
– Pale stool
– Jaundice
– Stomach pain
– Side pain
A person may have all, some or none of these
• Symptoms

13. • Close personal contact
(e.g., household contact, sex contact,
child day care centers)
• Contaminated food, water
(e.g., infected food handlers, raw
shellfish)
• Blood exposure (rare)
(e.g., injecting drug use, transfusion)
Hepatitis A Virus Transmission

14. Laboratory Diagnosis
• Acute infection is diagnosed by the
detection of HAV-IgM in serum by EIA.
• Past Infection i.e. immunity is determined
by the detection of HAV-IgG by EIA.

15. Hepatitis A
• Treatment
– No medicine or treatment to make it go away
– Rest, fluids, treatment of symptoms
– Most people recover completely and become
immune to reinfection

16. Hepatitis A
• Prevention
– Shot of immune globulin up to 2 weeks after
exposure
– Good hand washing
– Cook food well
– Good diaper hygiene
– Only drink clean water
– VACCINE!!!

17. Hepatitis A
• Who needs immune globulin?
– Living with someone with Hep A
– Eaten food handled by someone with Hep A
– Sexual contact with person with Hep A
– Traveling to an area where Hep A is common
– Child or employee at a child care program
where someone else has Hep A

18. Hepatitis B
–Hep B is a serious disease caused by
a virus that infects the liver
–Can cause lifelong infection,
cirrhosis (liver scarring), liver
cancer, liver failure and death

19. Hepatitis B Virus

20. Geographic Distribution of Chronic HBV
Infection
HBsAg Prevalence
8% - High
2-7% - Intermediate
<2% - Low

21. Hepatitis B
• Incubation period
– 60-90 days on average (range 45-180 days)
– infectious weeks before getting ill and for
variable period after acute infection
– chronic carriers remain infectious

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

23. Hepatitis B
– Nausea
– Loss of appetite
– Vomiting
– Fatigue
– Fever
– Dark urine
– Pale stool
– Jaundice
– Stomach pain
– Side pain
A person may have all, some or none of these
• Symptoms

24. Hepatitis B
• Risk groups
– Anyone can get it
– In the USA, 200,000 people get Hep B every
year
– 5,000 people die every year of Hep B
– If any other kinds of Hepatitis more chance to
get Hep B

25. Hepatitis B Infections
200,000 per year
Asymptomatic Cases
100,000 (50%)
Symptomatic Cases
100,000 (50%)
Death
100 (0.05%)
Chronic Liver Disease
Death from Cirrhosis
3400 (1.7%)
Death-Primary Liver Cancer
800 (0.4%)
Hepatitis B Chronic Carriers
12-20,000 (6-10%)
Clear Virus; Healthy
170 - 182,000 (90-94%)

26. Hepatitis B
• Who is at highest risk?
– Injection drug users
– Sex partners of those with Hep B
– Sex with more than one partner
– Men who have sex with men
– Living with someone with chronic Hep B
– Contact with blood
– Transfusions, travel, dialysis

27. Hepatitis B
• How do you get it?
– Direct contact with blood or body fluids of an
infected person
• sharing injection equipment
• sex
• baby from infected mother during
childbirth
• Hepatitis B is not spread by food, water or
casual contact

28. Hepatitis B
• Who is a carrier of Hep B virus?
– Some people with Hep B never fully recover
from the infection (chronic infection)
– They still carry the virus and can infect others
for the rest of their lives
– There are about 1 million carriers of Hep B in
the USA

29. 10%
90%
Chronically infected
Clear the infection
HEPATITIS B

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

31. Diagnosis
• A battery of serological tests are used for
the diagnosis of acute and chronic hepatitis
B infection.
• HBsAg - used as a general marker of
infection.
• HBsAb - used to document recovery
and/or immunity to HBV infection.
• anti-HBc IgM - marker of acute infection.
• anti-HBcIgG - past or chronic infection.
• .

32. Cont……
• HBeAg - indicates active replication of
virus and therefore infectiveness.
• Anti-Hbe - virus no longer replicating.
However, the patient can still be positive for
HBsAg which is made by integrated HBV.
• HBV-DNA - indicates active replication of
virus, more accurate than HBeAg especially
in cases of escape mutants. Used mainly for
monitoring response to therapy

33. Treatment
• Interferon - for HBeAg +ve carriers with chronic active
hepatitis. Response rate is 30 to 40%.
• Lamivudine - a nucleoside analogue reverse transcriptase
inhibitor. Well tolerated, most patients will respond
favorably. However, tendency to relapse on cessation of
treatment. Another problem is the rapid emergence of drug
resistance.

34. • Successful response to treatment will result
in the disappearance of HBsAg, HBV-
DNA, and seroconversion to HBeAg.

35. Hepatitis B
• What about Hep B and pregnancy?
– A woman with Hep B can give it to her baby at
birth
– Babies with Hep B can get very sick, can
develop chronic infection and spread Hep B,
can get cirrhosis or liver cancer
– Pregnant women should be tested for Hep B
– Babies should get Hep B vaccine at birth

36. Hepatitis B
• Who should get Hepatitis B vaccine?
– All babies, at birth
– All children 11-12 who have not had vaccine
– People at risk
• MSM
• Multiple sex partners
• Injection drug users
• People with jobs where exposure to blood might
happen

37. Prevention
• Vaccination - highly effective recombinant vaccines are now
available. Vaccine can be given to those who are at increased
risk of HBV infection such as health care workers. It is also
given routinely to neonates as universal vaccination in many
countries.
• Hepatitis B Immunoglobulin - HBIG may be used to protect
persons who are exposed to hepatitis B. It is particular
efficacious within 48 hours of the incident. It may also be given
to neonates who are at increased risk of contracting hepatitis B
i.e. whose mothers are HBsAg and HBeAg positive.
• Other measures - screening of blood donors, blood and body
fluid precautions.

38. Hepatitis C
Hep C is a liver infection caused by a virus
– Also known as non A, non B hepatitis

39. Hepatitis C
• Incubation period
– 6-7 weeks on average (range 2-6months)
– infectious one or more weeks before getting ill
– chronic carriers remain infectious

40. Hepatitis C
– Nausea
– Loss of appetite
– Vomiting
– Fatigue
– Fever
– Dark urine
– Pale stool
– Jaundice
– Stomach pain
– Side pain
• Symptoms
3 out of 4 persons have no symptoms and can
infect others without knowing it

41. Hepatitis C
• Who is at risk?
– About 35,000 people get Hep C every year
• down from 180,000 in the 1980s
– About 3.9 million people in the USA are
infected with Hep C.
– It can cause liver failure, cirrhosis, liver cancer
– Responsible for 8,000 to 10,000 deaths/year.

42.  Transfusion or transplant from infected donor
 Injecting drug use
 Hemodialysis (yrs on treatment)
 Accidental injuries with needles/sharps
 Sexual/household exposure to anti-HCV-positive
contact
 Multiple sex partners
 Birth to HCV-infected mother
Risk Factors Associated
with Transmission of HCV

43. Hepatitis C
– Shared injection equipment (60% of new infections)
– Blood transfusion before May, 1992 (now only 1 in
100,000 chance of transmission)
– Blood transfer (HCW, tattoo, piercing …)
– Sex? (HCV in semen and vf but only 1.5% rate of
transmission for long-term partners)
– Mother to child (<5%)
– 10-20% of infections have no identifiable risk factors
• How do you get it?

44. Hepatitis C
• Diagnosis
– There is a blood test that screens for Hep C antibodies
(ELISA or RIBA)
– Antibodies usually develop within 3 months
– HIV+ persons may not develop detectable antibodies
– If infected, liver enzyme tests or a liver biopsy can
check liver function

45. Hepatitis C
• What happens when you have Hepatitis C ?
– 85% of people develop chronic infection (infected for
the rest of their life)
– Rapid progression, slow progression, no progression
• HCV subtype
• Alcohol consumption (alcoholics 3 times more likely to
develop cirrhosis after 20 years)
• age (older at time of infection more rapid)
• gender (men faster progression than women)

46. 85%
15%
Chronically infected
Clear the infection
HEPATITIS C

47. Hepatitis C
• Treatment
– Interferon/Ribaviron (suggest 40% “cure” rate)
– Peginterferon Alfa-2a (still in studies - not yet
FDA approved)

48. Hepatitis C
• What should a person do who has Hep C?
– Get regular medical care--tell doctor about ALL
drugs (including herbs)!!!
– Have a healthy diet (no iron supplements, reduce
salt intake, no large doses of vitamin A)
– Get needed rest
– No alcohol or Tylenol, cut back on other drug use
– Avoid chemical fumes and other environmental
toxins
– Get vaccinated for A and B!!!

49. Hepatitis C
• What should a person do who has Hep C?
– Do not share injection equipment.
– Do not donate blood or plasma, organs or sperm
– Do not share toothbrushes, razors
– Cover areas of open skin
– Use safer sex

50. HBsAg
RNA
 antigen
Hepatitis D (Delta) Virus

51.  Percutanous exposures
injecting drug use
 Permucosal exposures
sex contact
Hepatitis D Virus Modes
of Transmission

52. Hepatitis E Virus

53.  Incubation period: Average 40 days
Range 15-60 days
 Case-fatality rate: Overall, 1%-3%
Pregnant women,
15%-25%
 Illness severity: Increased with age
 Chronic sequelae: None identified
Hepatitis E - Clinical Features

54.  Most outbreaks associated with faecally contaminated drinking
water.
 Several other large epidemics have occurred since in the Indian
subcontinent and the USSR, China, Africa and Mexico.
 In the United States and other nonendemic areas, where
outbreaks of hepatitis E have not been documented to occur, a
low prevalence of anti-HEV (<2%) has been found in healthy
populations. The source of infection for these persons is
unknown.
 Minimal person-to-person transmission.
Hepatitis E -
Epidemiologic Features

56.  Avoid drinking water (and beverages with ice) of
unknown purity, uncooked shellfish, and uncooked
fruit/vegetables not peeled or prepared by traveler.
 IG prepared from donors in Western countries
does not prevent infection.
 Unknown efficacy of IG prepared from donors in
endemic areas.
 Vaccine?
Prevention and Control Measures
for Travelers to HEV-Endemic
Regions

57. Hepatitis
AVirus BVirus CVirus
Symptoms
of
Initial
Infection
 Some people have no symptoms (especially HCV)
 Eyes or skin may turn yellow (jaundice)
 Loss of appetite
 Nausea, vomiting, fever, stomach or joint pain
 Fatigue (can last weeks or months)
 Dark urine & pale bowel movements
Chronic
Infection
(Infection for
life)
No chronic disease 10% Chronic
Can cause:
Liver cell damage
Cirrhosis
Liver cancer
85% Chronic
Can cause:
Liver cell damage
Cirrhosis
Liver cancer
How is it
Spread?
 Fecal/ oral
 Contaminated
food and water
 Oral/Anal sexual
contact
 Blood and body
fluid contact
 Sex
 Needles
 Mother to baby
 Human bite
 Blood and body fluid
contact
 Needles
 Mother to baby
 Sex (minimal)
Vaccine Yes Yes No

58. THANK YOU……..