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Chronic Hepatitis 3.10.14.1.pptx
- 1. Dr. Ghulam Mustafa MBBS;MCPS;FCPS (peds) Associate Professor Fellow Pediatric Pulmonology & Intensive Care (Sg)
- 2. A Long Historyof Human Misery 400 B.C. “epidemic jaundice” 1947 infectious hepatitis “Hepatitis A” Serum hepatitis “Hepatitis B” 1973 Hepatitis A identified by electron microscopy 1989 He patitis C cloned 1990 Hepatitis E cloned Hippocrates
- 3. Clinical Terms • inflammationof liver; presence of inflammatory cells in organ tissue Hepatitis: • symptoms last less than 6 months Acute Viral Hepatitis: • Massive hepatic necrosis with impaired consciousness within 8 wks of onset of illness. Acute Hepatic Failure: • severe impairment of hepatic functions or severe necrosis of hepatocytes in the absence of preexisting liver disease Fulminant Hepatitis: • Inflammation of liver for at least 6 months Chronic Hepatitis:
- 8. Hepatitis B PerinatalTransmission* If mother positive for HBsAg and HBeAg 70%-90% of infants infected 90% of infected infants become chronic carriers If positive for HBsAg only 20% of infants infected 90% of infected infants become chronic carriers *in the absence of postexposure prophylaxis
- 9. Acute hepatitis B AcuteHepatitis B Virus clear 6 Months Virus first enters the body Healthy 90%
- 10. Acute hepatitis B AcuteHepatitis B Virus clear 6 Months Virus first enters the body Healthy 90% Protected from hep B for life “Immune”
- 11. 6 Months Acute hepatitisB Chronic Hepatitis B= Carrier Virus not clear Time of Infection Healthy 90%
- 12. Risk of DevelopingChronic Hepatitis B by Age at Infection Healthy 90% Carrier 90% Healthy 50% Carrier 50% Adults Infants children
- 13. Can my babydie from hepatitis B? • Most babies do not die from hepatitis B. carriers If babies get all 3 shots, + a shot called H-BIG, they have a 95% chance of being safe from hepatitis B for life. • 9/of 10 babies born to infected mothers will end up being hepatitis B carriers for the rest of their lives,
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- 15. HBsAg Prevalence 8% -High <2% - Low Geographic Distribution of Chronic Hepatitis B Source: CDC and Prevention Endemic Non Endemic
- 16. Transfusion and transplant recipients Individualswith multiple sexual partners Healthcare workers Hepatitis B: who is at risk?
- 17. Relative Transmission Efficiencyof Bloodborne Viral Infections +++ ++++ ++ +++ + ++ ++++ + ++ +++ +/– +/– HBV HCV HIV Injection-drug use Sexual Perinatal Occupational Hepatitis B is 100 times More infectious than Aids
- 18. Hepatitis B: A world-widepublic health problem • More than 2 billion exposed people • Currently 350 million HBV carriers • Over 1 million infected die each year • Three quarters of the world’s 5.2 billion people live in endemic regions • Established cause of chronic hepatitis and cirrhosis • Human carcinogen - cause of up to 80% of hepatocellular carcinomas
- 19. • 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
- 20. Hepatitis B Epidemiology •Reservoir Human. Endemic • Transmission Bloodborne Sub clinical cases transmit • Communicability 1-2 months before and after onset of symptoms Chronic carriers
- 21. • Incubation periodAverage 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% >5yrs, 2%-10% • Premature mortality 15%-25% from chronic liver disease Hepatitis B—Clinical Features Source: CDC and Prevention
- 22. Fulminant hepatitis Hospitalization Cirrhosis Hepatocellular carcinoma Death Hepatitis B Complications
- 23. Risk of DevelopingChronic Hepatitis B by Age at Infection 0 20 40 60 80 100 Infant 1-5 years >5 years %
- 24. Possible Outcomes of HepatitisB Infection Possible Outcomes of Hepatitis B Infection Recovery Chronic HBV infection Fulminant hepatitis HBsAg carrier Reactivation Cirrhosis HCC Chronic hepatitis B HBeAg positive Chronic hepatitis B HBeAg positive HDV superinfection Chronic hepatitis B HBeAg positive Acute HBV infection
- 25. Estimated Number ofPersons with Chronic Bloodborne Virus Infections 1998 Region Population (millions) (millions) HIV HCV HBV Africa 749 22.7 22.5 59.3 Asia 3,585 7.3 107.5 286.8 Latin America 504 1.7 15.1 10.3 Europe 729 0.8 21.8 10.9 Oceania 30 0.0 0.9 2.4 North America 305 0.9 9.1 1.9 Total 5,902 33.4 176.9 371.6 Chronic infections
- 26. Symptoms HBeAg anti-HBe Total anti-HBc IgManti-HBc anti-HBs HBsAg 0 4 8 12 16 20 24 28 32 36 52 100 Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Weeks after Exposure Titer Source: CDC and Prevention
- 27. IgM anti-HBc Total anti-HBc HBsAg Acute (6months) HBeAg Chronic (Years) anti-HBe 0 4 8 12 16 20 24 28 32 36 52 Years Progression to Chronic Hepatitis B Virus Infection Typical Serologic Course Weeks after Exposure Source: CDC and Prevention
- 28. Age at Acquisitionof Acute and Chronic HBV Infection United States, 1989 Estimates Adults 83% Adults 59% (4%) Perinatal (24%) (4%) Children (12%) (1 –10 years) (8%) Adolescents (6%) Acute HBV Infections Chronic HBV Infections
- 29. Possible Outcomes of HepatitisB Infection Possible Outcomes of Hepatitis B Infection Recovery Chronic HBV infection Fulminant hepatitis HBsAg carrier Reactivation Cirrhosis HCC Chronic hepatitis B HBeAg positive Chronic hepatitis B HBeAg positive HDV superinfection Chronic hepatitis B HBeAg positive Acute HBV infection
- 30. Estimated Number ofPersons with Chronic Bloodborne Virus Infections 1998 Region Population (millions) (millions) HIV HCV HBV Africa 749 22.7 22.5 59.3 Asia 3,585 7.3 107.5 286.8 Latin America 504 1.7 15.1 10.3 Europe 729 0.8 21.8 10.9 Oceania 30 0.0 0.9 2.4 North America 305 0.9 9.1 1.9 Total 5,902 33.4 176.9 371.6 Chronic infections
- 31. Age at Acquisitionof Acute and Chronic HBV Infection United States, 1989 Estimates Adults 83% Adults 59% (4%) Perinatal (24%) (4%) Children (12%) (1 –10 years) (8%) Adolescents (6%) Acute HBV Infections Chronic HBV Infections
- 32. Source: CDC ViralHepatitis Surveillance Program Age Group (Years) Rate of Reported Hepatitis B by Age Group United States, 1990
- 33. Pediatric Deaths Dueto Vaccine Preventable Diseases (VPD) (aged < 12 years) Varicella 1 Pneumococcal Disease 3 H. Influenza Disease 6 Measles l0 Hepatitis B 25** * Pre-vaccine era ** Most HBV deaths are deferred until 15-30 years from time of perinatal/childhood exposure Estimated Annual VPD Deaths in Wisconsin*
- 34. Concentration of HepatitisB Virus in Various Body Fluids High Moderate Low/Not Detectable blood semen urine serum vaginal fluid feces wound exudates saliva sweat tears breast milk
- 35. Blood transfusion 0% Other* 15% Unknown32% Hemodialysis 0% Multiple sex partners 17% Injection drug use 14% Men who have sex with men 6% Sexual contact with hepatitis B patient 13% Medical Employee 1% Household contact of hepatitis B patient 2% Risk Factors Associated with Reported Hepatitis B, 1990-2000, United States Source: NNDSS/VHSP *Other: Surgery, dental surgery, acupuncture, tattoo, other percutaneous injury
- 36. Concentration of HepatitisB Virus in Various Body Fluids High Moderate Low/Not Detectable blood semen urine serum vaginal fluid feces wound exudates saliva sweat tears breast milk
- 37. Relative Transmission Efficiencyof Bloodborne Viral Infections +++ ++++ ++ +++ + ++ ++++ + ++ +++ +/– +/– HBV HCV HIV Injection-drug use Sexual Perinatal Occupational
- 38. Interpretation of DiagnosticTests for Hepatitis B Acute Past Exposures Previous Test Hepatitis B (Immunity) Immunization HBsAg + – – anti-HBs – + + HBeAg + – – anti-HBe – +/ – – anti-HBc + + – IgM anti-HBc + – – HBV DNA* + – – ALT Elevated Normal Normal *By conventional assay. A lower level of viremia may be detected by other more sensitive tests such as PCR.Shetty K et al Practical Gastroenterology 1998;22:39-47.
- 39. Chronic Chronic Healthy TestHepatitis B Precore Carrier HBsAg + + + anti-HBs – – – HBeAg + – – anti-HBe – + + anti-HBc + + + IgM anti-HBc – – – HBV DNA* +/ – +/ – – ALT Elevated Elevated Normal Interpretation of Diagnostic Tests for Hepatitis B (cont.) *By conventional assay. A lower level of viremia may be detected by other more sensitive tests such as PCR. Shetty K et al Practical Gastroenterology 1998;22:39-47.
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