Dr Hassan K.S
MBBS, Ilorin
21 August, 2013
outlines
 Introduction/background
 Epidemiology/burden
 Virology/ pathophysiology
 Mode of transmission
 Management o...
Introduction
 Hepatitis B virus(HBV) is a hepatotropic
virus discovered in 1966
 Has infected more than 2billions people...
Introduction
 Clinical presentation ranges from
subclinical to symptomatic hepatitis; in rare
instances fulminant hepatit...
Epidemiology/global burden
International statistics
 HBV infects more than 350 million people worldwide.
 Approximately ...
Hepatitis B In the World
 10-30 million will become infected each
year.
 Approximately 2 people die each minute
from hep...
Symptomatic Infection
Chronic Infection
Age at Infection
Chronic Infection (%)
SymptomaticInfection(%)
Birth 1-6 months 7-...
Global Patterns of
Chronic HBV Infection
 High (>8%): 45% of global population
 lifetime risk of infection >60%
 early ...
Hepatitis B In the United
States
 12 million Americans have been infected (1
out of 20 people).
 More than one million p...
 An estimated 25,000 infants are born to
hepatitis B surface antigen (HBsAg)-
positive women annually in the United
State...
Hepatitis B Disease Progression
Acute
Infection
Chronic
Infection Cirrhosis
Death
5%-10% of
chronic HBV-
infected
individu...
Virology
 It is a circular partially dsDNA virus
 Hepadnaviridae family (DNA)
 Numerous antigenic components
 HBsAg,HB...
HBV : Structure
 Virion also referred to as Dane particle (ds-stranded
DNA)
 42nm enveloped virus
 Core antigens locate...
HBV : Structure
Transmission
 Perinatal exposure
 Percutaneous exposure
 Sexual exposure
Transmission
 The virus is transmitted via parenteral or mucosal
exposure to HBV infected fluid
 Perinatal transmission ...
 The overall rate of transmission of HBV
from an infected HBsAg-positive mother to
her neonate during the perinatal perio...
Hepatitis B Perinatal
Transmission
 If mother positive for HBsAg and
HBeAg
 70%-90% of infants infected
 90% of infecte...
High Moderate
Low/Not
Detectable
blood semen urine
serum vaginal fluid feces
wound exudates saliva sweat
tears
breastmilk
...
Management of exposed
infants
 Mother is HBsAg Positive
 Give 0.5 mL of HBIG and 0.5 mL of single-
antigen hepatitis B v...
 Test for HBsAg and hepatitis B surface antibody
(anti-HBs) 1-2 months after completing at least three
dose in the HBV va...
 Low birth weight infants (less than 2000 grams)
should receive a single-antigen birth dose but
this dose should not be c...
Mother Has Unknown HBsAg
Status at Time of Birth
 Begin the single-antigen hepatitis B vaccine
series within 12 hours of ...
 Low birth weight infants (less than 2,000 grams)
should receive both single-antigen hepatitis B
vaccine and HBIG (0.5 mL...
Mother is HBsAg Negative
 Give 0.5 mL of single-antigen hepatitis B
vaccine intramuscularly before the infant is
discharg...
 The child should complete the remaining
three doses of vaccine per the
immunization schedule for full term
infants, maki...
 Impact of perinatal HBV transmission
○ Unlike adults who have a high rate of
spontaneous clearance of HBV following
acut...
 In those mothers with HBeAg, the risk of
HBV perinatal transmission is reduced
from 70-90% to approximately 5-15%
when t...
Hep B serological markers
Prevention of perinatal
transmission of HBV
 Universal prenatal HBsAg screening
 Further evaluation of HBsAg +ve
pregnan...
Management of hbv exposed infants
Management of hbv exposed infants
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Management of hbv exposed infants

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Management of hbv exposed infants

  1. 1. Dr Hassan K.S MBBS, Ilorin 21 August, 2013
  2. 2. outlines  Introduction/background  Epidemiology/burden  Virology/ pathophysiology  Mode of transmission  Management of exposed infants  Post exposure prophylaxis and follow up  HBV antigenic markers
  3. 3. Introduction  Hepatitis B virus(HBV) is a hepatotropic virus discovered in 1966  Has infected more than 2billions people worldwide  An established cause of chronic hepatitis  Human carcinogen cause of upto 80% of hepatocellular carcinoma;2nd only to tobacco  HBV causes acute and chronic liver diseases
  4. 4. Introduction  Clinical presentation ranges from subclinical to symptomatic hepatitis; in rare instances fulminant hepatitis  Long term complication include cirrhosis and HCC  In addition to human sufferings the social and economics implications of these diseases are huge  More than $1billion dollars are spent yearly for hep B related hospitalization
  5. 5. Epidemiology/global burden International statistics  HBV infects more than 350 million people worldwide.  Approximately 5% of the world's population has chronic HBV infection  It is the leading cause of chronic hepatitis, cirrhosis, and hepatocellular carcinoma worldwide.  Each year, an estimated 500,000 people die of cirrhosis and hepatocellular carcinoma caused by chronic infection  And an additional 40,000 people die of acute hepatitis B.  An estimated 500,000-1,000,000 persons die annually from HBV-related liver disease.
  6. 6. Hepatitis B In the World  10-30 million will become infected each year.  Approximately 2 people die each minute from hepatitis B.  25-40% of chronic hepatitis patient die from liver cirrhosis and HCC
  7. 7. Symptomatic Infection Chronic Infection Age at Infection Chronic Infection (%) SymptomaticInfection(%) Birth 1-6 months 7-12 months 1-4 years Older Children and Adults 0 20 40 60 80 100100 80 60 40 20 0 Outcome of Hepatitis B Virus Infection by Age at Infection ChronicInfection(%)
  8. 8. Global Patterns of Chronic HBV Infection  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
  9. 9. Hepatitis B In the United States  12 million Americans have been infected (1 out of 20 people).  More than one million people are chronically infected .  Up to 100,000 new people will become infected each year.  5,000 people will die each year from hepatitis B and its complications.  Approximately 1 health care worker dies each day from hepatitis B.
  10. 10.  An estimated 25,000 infants are born to hepatitis B surface antigen (HBsAg)- positive women annually in the United States. With no intervention, 40%–90% of these infants will acquire hepatitis B virus (HBV) infection  Approximately 90% of infected infants develop chronic HBV infection, with a 15%–25% risk for premature death from cirrhosis or cancer of the liver
  11. 11. Hepatitis B Disease Progression Acute Infection Chronic Infection Cirrhosis Death 5%-10% of chronic HBV- infected individuals1 Liver Failure (Decompensation ) >30% of CHB individuals1 • >90% of infected children progress to chronic disease • <5% of infected immunocompetent adults progress to chronic disease1 24% of patients decompensate within 5 years of developing cirrhosis 2 Liver Cancer (HCC) Liver Transplantation • Torresi J, Locarnini. Gastroenterology 2000. • Fattovich G et al. Hepatology 1995
  12. 12. Virology  It is a circular partially dsDNA virus  Hepadnaviridae family (DNA)  Numerous antigenic components  HBsAg,HBeAg, HBcAg  Humans are only known host  Resilient virus  Infectious on surfaces for >7days at room temp
  13. 13. HBV : Structure  Virion also referred to as Dane particle (ds-stranded DNA)  42nm enveloped virus  Core antigens located in the center (nucleocapsid) * Core antigen (HBcAg) * e antigen (HBeAg)- an indicator of transmissibility (minor component of the core- antigenically distinct from HBcAg)  22nm spheres and filaments other forms- no DNA in these forms so they are not infectious (composed of surface antigen)- these forms outnumber the actual virions
  14. 14. HBV : Structure
  15. 15. Transmission  Perinatal exposure  Percutaneous exposure  Sexual exposure
  16. 16. Transmission  The virus is transmitted via parenteral or mucosal exposure to HBV infected fluid  Perinatal transmission from mother at birth is very efficient  The precise mechanism of HBV transmission remains unclear,  It appears that infection occur predominantly intrapartum or, rarely, in utero(transpacental).  Hepatitis B viral DNA and HBsAg have been detected in amniotic fluid, placental cells, and vaginal secretions of HBsAg-positive women during pregnancy and in cord blood of their neonates  Transmission of HBV through breast milk is not a significant source of infection
  17. 17.  The overall rate of transmission of HBV from an infected HBsAg-positive mother to her neonate during the perinatal period ranges from 5-90%  This risk depends on whether the mother also has a positive hepatitis B e antigen (HBeAg) test or/and high viral load  The mode of delivery (vaginal versus caesarean) does not appear to have an impact on the risk for perinatal HBV infection
  18. 18. Hepatitis B Perinatal Transmission  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
  19. 19. 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
  20. 20. Management of exposed infants  Mother is HBsAg Positive  Give 0.5 mL of HBIG and 0.5 mL of single- antigen hepatitis B vaccine within 12 hours of birth. Both HBIG and vaccine should be given intramuscularly at different sites.  Give subsequent doses of hepatitis B vaccine according to the immunization schedule for a child born to a mother who is HBsAg positive.  All children born to women who are HBsAg positive should receive follow-up to ensure the child has completed the vaccine series and that immunoprophylaxis was successful.
  21. 21.  Test for HBsAg and hepatitis B surface antibody (anti-HBs) 1-2 months after completing at least three dose in the HBV vaccine series (e.g. at 9-18 months of age, generally at the next well-child visit). ○ Screening should not be performed before 9 months of age, or earlier than 4 weeks following the last vaccine dose. ○ Children with anti-HBs levels 10 mIU/mL or greater have responded appropriately to the vaccine series and thus do not need additional follow-up. ○ Children with anti-HBs levels less than 10 mIU/mL should be revaccinated with a second three-dose hepatitis B series and retested for anti-HBs 1-2 months after completing the vaccine series. ○ HBsAg positive children will need life-long follow-up for their HBV infection.
  22. 22.  Low birth weight infants (less than 2000 grams) should receive a single-antigen birth dose but this dose should not be counted towards the three dose series. The full three dose series should be started at 1-2 months of age; thus, these children should receive a total of four vaccine doses due to the theoretical risk of a poor immune response to immunization. ○ Test for HBsAg and hepatitis B surface antibody (anti-HBs) 1-2 months after completing the fourth dose in the HBV vaccine series and then manage as in 1.d.i-iii.
  23. 23. Mother Has Unknown HBsAg Status at Time of Birth  Begin the single-antigen hepatitis B vaccine series within 12 hours of birth while the mother's HBsAg test is pending.  If the mother's HBsAg test result is positive, the child should receive 0.5 mL of HBIG intramuscularly as soon as possible (within 72hrs of birth) and the vaccine series and screening should be completed.  If the mother's HBsAg test result is negative, the child should receive the routine series of preventive hepatitis B vaccine.
  24. 24.  Low birth weight infants (less than 2,000 grams) should receive both single-antigen hepatitis B vaccine and HBIG (0.5 mL) if the mother's HBsAg status cannot be determined within 12 hours of birth.  The birth dose of vaccine should not be counted towards the three dose series.  The full three dose series should be started at 1 months of age; thus, these children should receive a total of four vaccine doses due to the theoretical risk of a poor immune response to immunization. ○ Test for HBsAg and hepatitis B surface antibody (anti- HBs) 1-2 months after completing the fourth dose in the HBV vaccine series and then manage accordingly
  25. 25. Mother is HBsAg Negative  Give 0.5 mL of single-antigen hepatitis B vaccine intramuscularly before the infant is discharged from the hospital and complete the series accordingly .  If a child is not immunized before discharge, single-antigen vaccine should be given within a month of birth and the series should be completed accordingly.  Medically stable, low birth weight infants (less than 2,000 grams) should receive their first dose 1 month after birth.
  26. 26.  The child should complete the remaining three doses of vaccine per the immunization schedule for full term infants, making sure the 2nd dose is given at least 1month after the first dose
  27. 27.  Impact of perinatal HBV transmission ○ Unlike adults who have a high rate of spontaneous clearance of HBV following acute infection, approximately 90% of children infected during the perinatal period develop chronic infection, and up to 25% will develop chronic active hepatitis as adults.  Susceptible children not infected in the perinatal period are at risk for infection from horizontal transmission of HBV in the first five years of life
  28. 28.  In those mothers with HBeAg, the risk of HBV perinatal transmission is reduced from 70-90% to approximately 5-15% when the infant receives postnatal immunoprophylaxis with both hepatitis B immune globulin (HBIG) and hepatitis B vaccine series  the risk is reduced to approximately 20% with regimens that use multiple doses of HBIG only or the vaccine series alone
  29. 29. Hep B serological markers
  30. 30. Prevention of perinatal transmission of HBV  Universal prenatal HBsAg screening  Further evaluation of HBsAg +ve pregnant women  Antiviral therapy/immunotherapy before delivery to lower viral load  Infant immunoprophylaxis

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