viral heaptitis diganosis and management

1. ACUTE VIRAL HEPATITIS
CLINICAL PRESENTATION.
DIGNOSIS.
EPEDEMOLOGY OF VIRAL
HEPATITIS INFECTION A,B,C IN
KSA.
MANAGEMENT.

2. Viral Hepatitis - Overview
Viral Hepatitis - Overview
A
A B
B C
C D
D E
E
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
Type of Hepatitis

3. Diagnosis of hepatitis
Patient history
Physical examination
Liver function tests
Serologic tests

4. Symptoms and Signs
Pre-icteric phase
1. Anorexia
2. Fatigue
3. Nausea
4. Vomiting
5. Arthralgia
6. Myalgia
7. Headache
8. Photophobia
9. Pharangitis
10.
11.

5. Icteric phase::
1. Enlarged liver
2. Tender upper quadrant
3. Discomfort
4. Splenomegaly (10-20%)
5. General adenopathy
Post-icteric phase

6. Lab Findings
1. L FT increase >5-10 times of normal
2. Markers of hepatitis B or C or A might be
positive

7. Pathological findings
1. Pan lobular infiltration with mononuclear
cells
2. Hepatic cell necrosis
3. Reticulum framework are intact

8. DD:
1. Infectious Mononucleosis
2. Drug Induced Hepatitis
3. Chronic Hepatitis.
4. Alcohol Hepatitis
5. Cholecystitis, Cholelithiasis

9. Complications
1.Chronic hepatitis  cirrhosis- HCC
2.Fulmnant hepatitis

10. FULMINANT HEPATITIS
Definition: Hepatic Failure Within 8 Weeks
Of Onset Of Illness.
Manifestation: Encephalopathy and
Prolonged PT
Histopathology: Massive Hepatic Necrosis.

11. Hepatitis B - Clinical Features
Hepatitis B - Clinical Features
• 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%

12. HBV infection
Factors affecting transmission ability
1.Replicative status
- HBeAg
- high HBVDNA
2.Route of infection
- percutanouse
- Transmucosal
3. Exposure frequency : Single vs. Multiple
4. Inoculums size : transfusion vs. needle stick

13. Hepatitis B

14. Hepatitis B serology
anti-HBc exposure (IgM = acute)
HBsAg  infection (carrier)
anti-HBs  immunity
HBeAg  viral replication
anti-HBe  seroconversion
HBV-DNA  viral replication

18. Natural History
Gow, BMJ 2001

19. • Sexual
• Parenteral
• Perinatal
Hepatitis B Virus
Modes of Transmission
Hepatitis B Virus
Modes of Transmission

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

21. Possible transmission route of HBV
in KSA
1-Horisontal transmission (person to person) is the main
transmission route
2-Perintal transmission (positive HBSAG mothers)
especially if they are HBEAG positive
3- Heterosexual transmission
4-Illegal injection drug use
5- Contaminated equipment used for therapeutic
injections and other health care related procedures
6- Folk medicine practice
7-Blood and blood products transfusion without prior
screening

22. HBV INFECTION
before and after
vaccination program

23. OVERALL PREVALENCE OF HBsAg AMONG
SAUDIS IN THE 80’S ACCORDING TO REGIONS
5.5
8.9
9.6
8.3
0
2
4
6
8
10
Central (n=6649) South-western
(n=7235)
Eastern
(n=8300)
Total (n=32183)
Positivity
(%)
Al-Faleh. Annals of Saudi Medicine, 1988

24. PREVALENCE OF HBeAg AMONG HBsAg POSITIVE
SAUDIS PREGNANT WOMEN (n = 20920)
3.7
5.4
0
1
2
3
4
5
6
%of HBsAg pos. %of HBeAg Pos.
Al-Faleh, Annals of Saudi Medicine, 1988

25. FREQUENCY OF HBeAg AMONG HBsAg
POSITIVE SAUDI CHILDREN (n=307)
17.2
19.4
17.1
17.9
15.5
16
16.5
17
17.5
18
18.5
19
19.5
Percent
1-3 years
(93/16)
4-6 years
(103/20)
7-10 years
(111/19)
Total
(307/55)
Al-Faleh et al. Journal of Infection, 1992

26. PREVENTION STRATEGIES OF
MINISTRY OF HEALTH IN KSA
Introducing HBV vaccine in EPI program; and
Mandatory screening of blood donors
and expatriates.
Vaccination of risk groups.
Health education especially among
medical personnel.

27. THE CURRENT EPI IN THE
KINGDOM OF SAUDI ARABIA
1. At birth BCG + HB1
2. At 6 weeks DPT1 + OPV1 Hb2
3. At 3 months DPT2 + OPV2
4. At 5 months DPT3 + OPV3
5. At 5months Measles HB3
6. At 12 months MMR
7. At 18 months (DPT + OPV) Booster 1
8. At 4-6 years (DPT + OPV) Booster 2

28. COMPARISON OF PREVALENCE OF HBsAg
AMONG SAUDI CHILDREN IN 1989 (n=4575)
AND 1997 (n=5355) – ACCORDING TO AGE
9.68
0 0
6.54
0.16
7.24
0.3
5.06
0
6.35
0
7.57
0.2
6.51
0.82
7.2
0.93
5.81
2.31
0
6
6.71
0.31
0
2
4
6
8
10
Percentage
1
2
3
4
5
6
7
8
9
10
11
12
Total
(Age in years)
1989 1997
Al Faleh, J Infect 1999

29. COMPARISON OF PREVALENCE OF HBsAg
AMONG SAUDI CHILDREN IN 1989 (n=4575)
AND 1997 (n=5355) – ACCORDING TO REGION
8.63
0
3.48
0.52
2.87
0
5.83
0.83
5.71
0
10.29
1.52
7.59
0
8.83
0.77
5.22
0
9.04
0
12.67
0.47
3.14
0
3.73
0.3
7.53
0
6.71
0.31
-1
1
3
5
7
9
11
13
Percentage
Riyadh
Qassim
Hail
Makkah
Medina
Aseer
Al-Baha
Gizan
Najran
Al-Jouf
Tabouk
Dammam
Jeddah
Taif
Total
1989 1997
Al Faleh, J Infect 1999

30. Prevalence Of HBsAg Among Saudi Population
Before & After Vaccination over 18 y
6.70%
0%
0.16%
0%
0%
2%
4%
6%
8%
10%
1989 1992 1997 2007/8
After
Before
1-10yr
4575
1-2yr
637
1-12yr
3666
Age
numbers
16-18yr
1365

31. CHANGING PATTERNS OF HBsAg POSITIVITY
AMONG BLOOD DONORS IN MOH,CENTRAL
BLOOD BANK 1994-2005
4.4
3.25
1.5
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
1994
n=9690
2000
n=91695
2005
n=177037

32. 0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Positivity
%
1987(n=
3565)
1991
(n=1991)
1996
(n=6885)
1997
(n=6285)
1998
(n=6031)
2002
(n=4793)
2003
(n=5472)
2004(n=9146)
2005(n=8361)
4.7
3
1.4
1.9
1.7
2 2.2
1 1
PREVALENCE OF HBsAg POSITIVITY AMONG
BLOOD DONORS IN KKUH FROM 1987 TO 2005

33. HBSAg positively Among Blood donors
in KKUH ( 18-21y)
0
0.2
0.4
0.6
0.8
1
1.2
1.4
positivity
%
2000 n= 647
(18- 20)
2004 n=1371
(18-20)
2005 n=1504
(18-21)
1.24
0.6 0.6

34. HCV INFECTION

40. Transmission of HCV
EGYPT, mass campaigns of parenteral
antischistosomal therapy(discontinued
only in the 1980 ) may represent the
WORLD, largest iatrogenic transmission of
BLOOD BORNN PATHOGENS
frank c,Moh m k et all lancet 2000

41. Natural history
Marcellin, J Hepat 1999

43. COMPARISON OF PREVALENCE OF ANTI-HCV IN
SAUDI CHILDREN IN 1989 AND 1997 STUDIES
1989 1997
No. of children Positive (%) No. of children Positive (%)
4496
39
(0.87%)
5350
2
(0.04%)
Diagnostic test only by
1st-generation EIA kit.
Diagnostic test by
3rd-generation EIA kit and
confirmatory test by RIBA
kit.

44. 1989 1997 2008
No. of
children
Positive (%)
No. of
children
Positive
(%)
No. of
students
Positive (%)
4496
39*
(0.87%)
5350
2**
(0.04%) 1357
(5)3
0.22%
Diagnostic test
only by
1st-generation EIA
kit.
Diagnostic test by
3rd-generation EIA
kit and confirmatory
test by RIBA kit.
Diagnostic test by
PCR for anti- HCV
Positive cases.
Overall prevalence rate of HCV infection in KSA
among children and adolescent during the last
18 yrs.
* ALFaleh et al. Hepatology 1991
** ALFaleh Ann Saudi Med. 2003

45. Prevalence of HCV Among Saudi
Blood donors (1998- 2002)
1.2
0.9
1.3
1.2
0.7
0
0.2
0.4
0.6
0.8
1
1.2
1.4
Precentage
1998
(n=104003)
1999
(n=110608)
2000
(n=114122
2001
(n=115090)
2002
(n=113993)
Shobokshi et al , SMJ 2003

46. HCV positivity among blood donors in 2005 in
central blood bank of MOH in KSA according to
regions
0.2
0.5
0.6
0.4
0.1
0.3
0.2
0.3 0.3
0
0.1
0.2
0.3
0.4
0.5
0.6
R
i
y
a
d
h
(
n
=
3
1
2
6
8
)
M
a
k
k
a
h
(
n
=
2
3
3
4
8
)
A
s
e
e
r
(
n
=
2
0
8
4
0
)
A
l
b
a
h
a
(
n
=
9
8
4
8
)
N
a
j
r
a
n
(
n
=
1
2
7
5
0
)
J
e
z
a
n
(
n
=
5
3
1
4
)
E
a
s
t
r
e
n
P
r
o
v
i
e
n
c
e
(
n
=
2
9
6
7
4
)
A
l
q
a
s
e
e
m
(
n
=
2
6
0
9
4
)
T
o
t
a
l
(
n
=
1
7
2
6
5
)

47. HCV positivity among Saudi blood donors from
1996 – 2005 in KKUH (n=58910)
0.58 0.55
0.36
0.22
0.28 0.3 0.3
0.14
0.2
0
0.2
0.4
0.6
0.8
Percentage
1996
(n=40)
1997
(n=35)
1998
(n=22)
1999
(n=13)
2000
(n=18)
2002
(n=15)
2003
(n=17)
2004
(n=11)
2005
(n=19)
KKUH Blood bank

48. HCV POSITIVITY AMONG SAUDI BLOOD DONORS
FROM 1996 TO 2000 IN KKUH
ACCORDING TO AGE GROUPS
0.17
0.53 0.69
4.4
0.38
0
1
2
3
4
5
Percentage
20-30 30-40 40-50 > 50 Total
(Age in years)
No. of blood donors = 32793
KKUH Blood bank

49. Prevalence of HCV Positivity
Among Different Saudi population
Type of patient number Prevalence(%)
Children from 1-18y 3854 0.1
Pregnant women 3127 0.7
Hemodialysis patients 29054 55.8
Drug addicts 9137 14
Shobokshi et al , SMJ 2003

50. Prevention Of HCV Transmission
Avoiding shared use of Razors or brushes
and any item that pierces the skin.
Strict adherence of the universal
precautions in health facilities.
Educating and training of HCW’s to the
proper use of standard precautions
Folk medicine?!

51. HAV INFECTION

56. COMPARISON OF PREVALENCE OF ANTI-HAV AMONG SAUDI
CHILDREN IN 1989 (n=4375) AND 1997 (n=5255) – ACCORDING
TO AGE
23.7
13.4
34.8
17.6
41.6
20.3
43.9
23.4
48.5
24
54.1
26.7
59.8
28
59.7
30.6
63.5
33.1
72.6
34.5
26.4
48.850.5
24.9
0
10
20
30
40
50
60
70
80
Percentage
1 3 5 7 9 11 Total
(Age in years)
1989 1997
Al-Faleh et al. Saudi Med. J, 1999

57. COMPARISON OF PREVALENCE OF ANTI-HAV
AMONG SAUDI CHILDREN IN 1989 (n=4375) AND
1997 (n=5255) – ACCORDING TO REGION
39
16.1
62.7
31.6
56
20.4
55
20.1
59.5
28.2
44.5
19
43.6
25.4
81.6
82.2
79.1
51.3
64.4
47.9
76
45.6
38.4
18.2
51.1
17.5 19
9.6
50.5
24.9
1
11
21
31
41
51
61
71
81
91
Percentage
Riyadh
Qassim
Hail
Makkah
Medina
Aseer
Al-Baha
Gizan
Najran
Al-Jouf
Tabouk
Dammam
Jeddah
Taif
Total
1989 1997

58. COMPARISON OF PREVALENCE OF ANTI-HAV
IN ASEER REGION AMONG SAUDI CHILDREN
IN 1989 (n=476) AND 1997 (n=411)
44.5
19
1
11
21
31
41
51
61
71
81
91
Percentage
1989 1997

59. PREVALENCE OF ANTI-HAV IN SAUDI
CHILDREN IN 1997 ACCORDING TO SEX
25.75
24
0
5
10
15
20
25
30
Percent
Male (n=2642) Female (n=2713)
No. of children = 5355

60. PREVALENCE OF ANTI-HAV IN SAUDI CHILDREN IN 1997
ACCORDING TO LOCATION
20.98
33.04
0
5
10
15
20
25
30
35
Percent
Urban (n=3635) Rural (n=1715)
No. of children = 5255

61. AGE SPECIFIC PREVALENCE OF ANTI-HAV IN SAUDIS
FROM RIYADH, CENTRAL REGION
Age
(Years)
1986 1994
P
No. Positive/
No. Tested
%
No. Positive/
No. Tested
%
1 – 9 103/194 53.0 81/210 38.6 3.4 x 10.3
10 – 19 164/193 85.0 110/180 61.1 1 x 10.4
20 – 30 182/200 91.0 188/240 78.3 3 x 10.4
Total 449/587 76.5 379/630 60.2 1 x 10.4
Arif et al. Saudi J Gastroenterology, 1995

62. Changing pattern of Hepatitis A prevalence
within the Saudi population over 18 yrs
53
24.3
18.1
0
10
20
30
40
50
60
1989 1999 2008
Age
Region
1-10 YRS
13
1-12 yrs
13
16-18 yrs
3
*
**
***
*AlRashed R. Ann SM 1997
** AlFaleh et al SMJ 1999
*** AlFaleh et al WJG 2008

66. THANK
YOU

73. • High (8%): 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
Global Patterns of Chronic HBV Infection
Global Patterns of Chronic HBV Infection

74. • High (8%): 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
Global Patterns of Chronic HBV Infection
Global Patterns of Chronic HBV Infection

76. Hepatitis C