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Viral Hepatitis MIU BCPS 2015
Viral Hepatitis MIU BCPS 2015
Hepatitis A
Fecal-oral spread: hygiene, drug use, sexual, travelers, day care,
food
Vaccine-preventable
Self resolving, very low mortality
Hepatitis B
Hepatitis C
blood borne (e.g. injection drug use) 10x more infectious than
HIV
5 times more prevalent than HIV in the US
Major problem in Egypt
NOT vaccine-preventable!
Chronicity: 85%
Hepatitis D
Only in patients co-infected with hepatitis B
Highest mortality rate of all hepatitis viruses (20%)
Transmission:
Incubation:
Fecal-oral spread: hygiene, drug use, sexual, travelers, day care, food (Water,
milk, shellfish, vegetables)
14-50 days
Symptoms:
abdominal pain
No chronocity
Diagnosis
Clinical signs and symptoms
Recent possible exposures
Laboratory data
Elevation of aminotransferases
IgM antibody to HAV (anti-HAV): before and during
infection. Presence indicate active or recent infection
IgG antibodies indicate previous infection and
provide lifelong protective immunity against
subsequent infection.
Result
Interpretation
Negative
Negative
Susceptible to
infection
Positive
Active infection
Positive
Immune due to
natural infection or
vaccination
Management:
Pre-exposure prophylaxis:
Active with vaccinations
Havrix (GlaxoSmithKline)
Vaqta (Merck)
Twinrix: combination HAV and HBV product
(GlaxoSmithKline)
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11
Post-exposure prophylaxis:
12
13
A.
B.
C.
D.
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A.
B.
C.
D.
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Transmission routes
16
Diagnosis:
Clinical signs and symptoms:
Nausea, vomiting, diarrhea, myalgia, fever,
abdominal pain, jaundice (30% may have no
symptoms)
17
18
Test
Results
Interpretation
HBsAg
anti-HBc
anti-HBs
Negative
Negative
Negative
Susceptible
(Never infected or vaccinated)
HBsAg
anti-HBc
anti-HBs
Negative
Negative
Positive
Immune
(Due to vaccine)
HBsAg
anti-HBc
anti-HBs
Negative
Positive
Positive
Immune
(Resolved Infection)
HBsAg
anti-HBc
IgM anti-HBc
anti-HBs
Positive
Positive
Positive
Negative
Acutely Infected
HBsAg
anti-HBc
anti-HBs
IgM anti-HBc
Positive
Positive
Negative
Negative
Chronically Infected
HBsAg
anti-HBc
anti-HBs
Negative
Positive
Negative
HBsAg
anti-HBc
anti-HBs
Negative
Positive
Negative
20
Screening:
Use HBV surface antigen (HBsAg)
21
22
Treatment is supportive.
fulminant hepatitis B
protracted, severe acute hepatitis B (increase in INR, severe
jaundice > 4 weeks)
Treatment options:
23
24
Goals of treatment:
sustained suppression of HBV replication
remission of liver disease
prevention of cirrhosis, hepatic failure, and
hepatocellular carcinoma
25
26
27
28
29
treatment options
Interferons
Peginterferon alfa-2a (long-acting) -180 mcg
subcutaneously once weekly for 48 weeks (AASLD
Grade I)
interferon alfa 2b (short-acting)
adult dose 5 million units/day or 10 million units 3
times/week subcutaneously (AASLD Grade I)
pediatric dose 6 million units/m2 (maximum 10 million
units) 3 times/week subcutaneously (AASLD Grade I)
30
Preferred agents:
Entecavir
Second line:
31
Nephrotoxicity (Adefovir)
CK elevation, peripheral neuropathy (Telbivudine)
32
treatment duration
interferon treatment regimen duration may range
from 12-48 weeks
nucleoside analogue treatment regimen duration
may range from 48-52 weeks
if HBeAg positive, goal of treatment is
seroconversion from HBeAg to anti-HBe antibody
33
34
Biochemical:
Liver function tests
Virologic:
Decrease of HBV DNA to undetectable level
Loss of HBeAg if HBeAg positive
Non-responders:
decrease in HBV DNA of less than 2 log/mL after
at least 24 weeks of therapy
Should receive alternate therapy
Viral Hepatitis Taher Hegab 2015
35
36
37
38
39
40
Genotype 1-6
Genotype 1 most common in US
Genotype 4 most common in Egypt
41
42
43
44
45
46
47
Goal of therapy
Attain SVR
(persistent absence of HCV RNA in serum 6 months or
more after completing antiviral treatment)
48
49
50
Category X drug
51
52
Drugs
Duration
12 weeks
12 weeks
12 weeks (no
cirrhosis)
24 weeks
(cirrhosis)
24 weeks
(cirrhosis)
53
Drugs
Duration
12 weeks
12 weeks (no
cirrhosis)
12 weeks
(cirrhosis)
12 weeks
54
55
56
57
Alternative regimen:
Daily Sofosbuvir (400 mg)
Plus
weight-based RBV (1000 mg [<75 kg] to 1200 mg [>75 kg])
Plus
plus weekly PEG-IFN
For
12 weeks
58
59
Drugs
Duration
12 weeks
12 weeks
24 weeks
60
Alternate regimens
Drugs
Duration
12 weeks
12 weeks
61
62
Treatment-naive patients:
63
64
65
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