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Acute Viral hepatitis (Hepatitis B (Hepatitis B Vaccine 2018 (ACIP…
Acute Viral hepatitis
Hepatitis B
- Hepadneviridae virus contains DNA
- 8 genotypes (A-H), most common in Poland A i D
- Course of infection silent or symptomatic
- Virus dyeing in temperature 160°C after 30 minutes autoclaving and 60 minutes in thermostat
- HBV is sensitive to active chlorine (chloramine, sodium chlorate)
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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%
Outcome of HBV Infection
- Resolved Immune
OR
- Chronic infection --> Cirrhosis, Liver cancer
Transmission
- Sexual, Parenteral, Perinatal
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Hepatitis B Vaccine 2018
- 3 dose series:
typical schedule 0, 1-2, 4-6 months
no maximum time between doses
no need to repeat missed doses or restart
- Protection ~30-50% dose 1; 75% - 2; 96% - 3;
lower in older
immunosuppressive illnesses (e.g., HIV, chronic liver diseases, diabetes)
obese, smokers
ACIP Recommendations
- Routine infant
- Over 18 – high risk
Occupational risk (HCWs), Hemodyalisis patients
All STD clinic clients, Multiple sex partners or prior STD
Inmates in Correctional settings, MSM
IDU, Institution for developmental disability
- Pre-vaccination testing – if cost effective
- Post-vaccination testing – 1-2 months after last shot, if establishing response critical (HCW)
serology
HBsAg: if positive infected with HBV (when disappears upon recovery, anti-HBs appears)
Anti-HBc: IgM – acute IgG – chronic
HBeAg: active viral replication (when HBeAg disappears, anti-HBe appears -> clearance of virus)
Patient has positive HBsAg, what does it mean?
- Patient is infected with HBV
- Patient is after immunoglobulin transfusion for passive immunization
- Vaccination against HBV
- Mother-to-child transplacental transmission (if in newborn)
Hepatitis A
- RNA Picornavirus
Single serotype worldwide
3 genotypes, 6 sub-genotypes
In Europe most dominant genotype IA
Genotype 4 (simian, rare in human)
Acute disease and asymptomatic infection
- No chronic infection
Protective antibodies develop in response to infection - confers lifelong immunity
- Virus sterilization
20 minutes in 100ºC, 120 minutes in 60ºC
Sensitive to UV light, chlorine, formalin
Clinical Features
- Incubation period: Average 30 days / Range 15-50 days
- Jaundice by age group: < 6 yrs: <10% / 6 – 14 yrs: 40%-50% / > 14 yrs: 70%-80%
- Rare Complications: Fulminant hepatitis, Cholestatic hepatitis, Relapsing hepatitis
- Chronic sequelae: None
- Fatal outcome: adult over 50 1.8%
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Transmission
- Fecal-oral
- Close personal contact
(e.g., household contact, sex contact, child day care centers)
- Contaminated food, water
(e.g., infected food handlers)
- Blood exposure (rare)
(e.g., injecting drug use, transfusion)
Prevention 2018
Vaccination (pre-exposure)
Immune globulin
Good hygiene
Clean water systems; avoidance of food contamination
- Groups at increased risk of infection
travelers to developing countries
men who have sex with men
illegal drug users
persons with chronic liver disease
Immune Globulin
- Pre-exposure:
travelers to intermediate and high
HAV-endemic regions
- Post-exposure (within 14 days)
Routine: household and other intimate contacts
Selected situations:
institutions (e.g., day care centers)
common source exposure (e.g.,food prepared by infected food handler)
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Hepatitis E
- Small RNA virus 4 genotypes, 1 serotype
- Hepevirus/Hepeviridae (previously Caliciviridae)
- Hepeviridae family
- Durable for heating 56°C 30 – 60 min
- Complete inactivation after 1h in temperature 66°C
genotypes
- HEV1 i HEV2
Food and water borne infection in human in developing countries
- HEV3 i HEV4
Infections in humans, pigs, wild boars, deer, rats, mongoose;
Infection in human after consumption of animal feed
Rare routs HEV infection
blood transfusion, vertical infection, nosocomial
Epidemiologic Features
- Most outbreaks associated with
fecally contaminated drinking water
- Minimal person-to-person transmission
Clinical Features
- 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: Probably in immunocompromised
- Therapy: Ribavirin 600-1000mg/daily – 21 days
- Prevention: Anti-HEV GT1
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Hepatitis C
Clinical Features
- Incubation period: Average 6 - 7 wks / Range 2 - 26 wks
- Acute illness (jaundice): Mild (≤20%)
- Case fatality rate: Low
- Chronic infection: 60%-85%
- Chronic hepatitis: 70%
- Cirrhosis: 5%-20%
- Mortality from CLD: 3%
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Testing
- Persons who ever injected illegal drugs
- Persons with selected medical conditions
received clotting factor concentrates produced before 1987
ever on chronic hemodialysis
evidence of liver disease
- Prior recipients of transfusion/organs
- Healthcare, emergency medical, and public safety workers after needle sticks, sharps, or mucosal exposures to HCV- positive blood
- Children born to HCV-positive women
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A, B, Cs of Viral Hepatitis
A
- fecal-oral spread: hygiene, drug use, men having sex with men, travelers, day care, food
- vaccine-preventable
B
- sexually transmitted – 100x more infectious than HIV
- blood-borne (sex, injection drug use, mother-child, and health care)
- vaccine-preventable
C
- blood borne (injection drug use primarily)
- 4-5 times more common than HIV
- NOT vaccine-preventable!
Hepatitis D
Clinical Features
- Coinfection with HBV
severe acute disease
low risk of chronic infection
- Superinfection on top of chronic HBV
usually develop chronic HDV infection
high risk of severe chronic liver disease
Transmission
- Percutanous exposures: injecting drug use
- Permucosal exposures: sex contact
Prevention
- HBV-HDV Coinfection
Pre or postexposure prophylaxis to prevent HBV infection (HBIG and/or Hepatitis B vaccine)
- HBV-HDV Superinfection
Education to reduce risk behaviors among persons with chronic HBV infection
Etiology
- Primary hepatotropic viruses
HAV, HBV, HCV, HDV(δ), HEV
HGV, GB (A,B,C), TTV, SEN
- Secondary hepatotropic viruses
Herpes family: CMV, EBV, HSV-1, HSV-2, VZV
Enteroviruses, rubella virus, mumps virus
yellow fever virus, Denga, haemorrhagic fever
Clinical Symptoms
- Symptoms (if present) are the same, regardless of cause (e.g., A, B, C, other viruses, toxins)
- Dark urine, Flu-like symptoms (fever, pain in joints and muscle)
- Loss of appetite, Nausea, vomiting
- Abdominal pain, Diarrhea
- Light (clay) colored stools, Jaundice (yellowing of eyes, skin)
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