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PDAT2 > 20/21 - Hep A & B > Flashcards

20/21 - Hep A & B Flashcards

1
Q

Pathophysiology of HAV

A

Mainly from Fecal-Oral Route > serum > saliva
could live in dried feces >4 weeks

from RAW seafood

does NOT cause CHRONIC DISEASE

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2
Q

HAV deographic distribution

A

HIGHEST in Africa / India
Mexico = south america = asia

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3
Q

anti-HAV IgM

Determines what?

A

Antibodies to Hep A IgM

Diagnoses ACUTE** **HAV

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4
Q

anti-HAV IgG

Determines what?

A

Past HAV Infection

or

  • *Lifelong IMMUNITY** to HAV Vaccine
  • may not need another dose*
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5
Q

Total anti-HAV

determines what?

A

Past HAV Infection

or

  • *Lifelong IMMUNITY** to HAV Vaccine
  • ​may not need another dose*
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6
Q

HBV Demographic Distriution

A

2 billion infected –> 257mil chronic

1 in 10 are ASIANS & PACIFIC ISLANDERS

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7
Q

HBV concentrations in Body fluids

A

HIGH:
BLOOD / SERUM / WOUND EXUDATES

Moderate:
semen / vaginal fluid / saliva

low / not detected:
urine / feces / sweat / tears / breast milk

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8
Q

HBV Transmission + Risk Factors

A

Blood + Infected Bodily fluids:
Percutaneous / SEXUAL / PERINATAL

Risk factors:
Vertical = perinatal/infants

Horizontal:
Children in day care , Sex > MM-Sex > Healthcare workers > travel

  • *Parenteral**:
  • *DIABETES** ( due to using the same meter / pen needles)
  • *IV drug users** / Blood transfusion / tatoos / acupuncture
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9
Q

HBV GEOGRAPHIC Distribution

A

HIGHEST in AFRICA

> Asia/Northern china

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10
Q

Effect of AGE OF ACQUISITION of HBV

A

Getting ACUTE HBV when you are YOUNG

= GREATER RISK to develop into CHRONIC HBV

Adults have a LARGER chance to
eliminate the infection / less chance to develop CHRONICITIY

(perinatal / as a child)

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11
Q

Hepatitis B Development into Chronicity

A

Adult Acquired = 10-15% -> Chronic

  • *Infant Acquired = 80-90% –> Chronic**
  • Inactive carrier* = 50%

Mild/Moderate Hepatitis = 20-30%

Cirrhosis = 8-20%

EVEN WITHOUT CIRRHOSIS –> CAN DEVELOP TO LIVER CANCER
(HCC = hepatocellular carcinoma)

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12
Q

Which Hepatitis can develop into HCC

even WITHOUT symptoms or Cirrhosis?

A

HBV

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13
Q

HBsAg

HEP B surface antigen

What does this help diagnose?

A

GOLD STANDARD = Marker of INFECTION
1st serologic marker to appear

Shows in serum 1-9 weeks post exposure
>6 mos = chronic infection​

Just tells if you if you have the infection,
does NOT tell if Chronic / Acute

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14
Q

anti-HBs

antibodies to HEP B surface antigens

What does this help diagnose?

A

If Positive & NO other markers = IMMUNITY/VACCINATED

Documents RECOVERY +/- IMMUNITY to HBV
Detectable after immunity conferred by HBV Vaccine

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15
Q

HBcAg

Hepatitis B CORE antigen

What does this help diagnose?

A

not useful in diagnosing active or chronic HBV

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16
Q

anti-HBc ( IgM )

antibody to hep B CORE IgM

What does this help diagnose?

A

ACUTE
HEPATITIS B INFECTION

IgM = ACUTE

M = making still

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17
Q

anti-HBc ( IgG )
Antibody to HEP B CORE IgG

What does this help diagnose?

A

can also be Total anti-HBc

  • *PREVIOUS_ or _CHRONIC**
  • *HBV**
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18
Q

HBeAg

Hep B ENVELOPE antigen

What does this help diagnose?

A

Indicates ACTIVE REPLICATION of HBV

is ABSENT in Pre-Core MUTANT HBV

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19
Q

anti-HBe

antibody to hep B envelope antigen

What does this help diagnose?

A

Indicates that:
Viral Replication has STOPPED or is DECREASING

patient can STILL be positive for HBsAg

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20
Q

HBV DNA

What does this help diagnose?

A

Use to ASSESS** & **QUANTIFY

HBV replication

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21
Q

HBV Genotyping

What does this help diagnose?

A

Helps determine the SEVERITY of the liver disease

&

Helps determine RESPONSE to IFN Therapy

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22
Q

HBV Genotypes, comparison of B vs C

A-J

A

A B C = Most Common
vary by location, B&C mainly in ASIA

B > C
in terms of IFN RESPONSE
&
BETTER in other ways
remission / preogression to cirrhosis / chronicity

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23
Q

Serological Test Chart for HBV

A
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24
Q

HDV Transmission

A

NEED TO HAVE HBV before you can get HDV
transmission is the same as HBV

Percutaneous = Injecting drug use

Permucosal = Sex

but RARE in vertical transmision

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25
Q

HDV CO-infection

A

You can be infected with
HBV & HDV
AT THE SAME TIME

most will recover,
<5% develop chronicity
may develop fulminant liver failure –> DEATH

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26
Q

HDV SUPERINFECTION

A

Already infected w/ HBV –> Acquire HDV LATER IN LIFE

more common than Co-infection:

Usually leads to
MORE SEVERE LIVER DISEASE / 70-90% Develop CIRRHOSIS

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27
Q

HEV
Distribution / Pathophysiology

A

Also found in the FECES** / **STOOL

Usually a SELF-LIMITING ACUTE Illness
HIGH mortality in pregnant women

& seen in Immunocompromised patients

4 genotypes, mainly in ASIA & AFRICA

CHINA has a HEV Vaccine

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28
Q

HGV Information

A

Transmission through BLOOD & SEXUAL CONTACT

found from blood donors

Liver is NOT a significant site of replication

May PREVENT cirrhosis in HIV patients

being researched

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29
Q

Agents for PREVENTION of HAV

A

HAND WASHING!

Immune Globulin = IG
gives passive TEMPORARY immunity, for post/pre-exposure

  • *Hep A VACCINE**
  • *active & LONG-TERM** immunity, also for post/pre-exposure
  • some may have HYPERSENSITIVITY to vaccine components = NEOMYCIN*
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30
Q

Immune Globulin = IG

for HAV

A

for PRE-Exposure = TRAVEL
for up to <1 Month of Travel, 1 dose
or 2+ months of Travel, greater dose / can REPEAT

for POST-exposure
1 dose weight based 0.1mL/kg

31
Q

HAV Vaccines

Dose / Names

A

HAVRIX
2 Doses, 2nd dose between month 6 - 12

INTERCHANGABLE

VAQTA
2 doses, 2nd dose between month 6 - 18

think 18 is greater & V>H

32
Q

When to give PRE-Exposure HAV
IG or HAV Vaccine

Healthy Traveler 1-40 years old

A

International Travel - Africa / Asia
Based on: AGE & TRAVEL TIME

HAV VACCINE ONLY
given ANYTIME prior to travel

33
Q

When to give PRE-exposure HAV
IG or HAV Vaccine

For traveler LEAVING < 2 WEEKS

A

International Travel - Africa / Asia
Based on: AGE & TRAVEL TIME

> 40 Years Old or Immunocompromised or Chronic Disease (+liver)

BOTH IG & HAV VACCINE

34
Q

When to give PRE-exposure HAV
IG or HAV Vaccine?

Traveler can NOT recieve HAV vaccine

A

International Travel - Africa / Asia
Based on: AGE & TRAVEL TIME

< 12 months old
(NOT approved for this age group)
ALLERGIC to vaccine / Choose NOT to

IG ONLY

35
Q

When to give POST-exposure HAV
IG / HAV Vaccine

A

Persons recently exposed to HAV & have NOT been VACCINATED

Give WITHIN 2 WEEKS AFTER exposure

HAV Vaccine
ONLY for Healthy 12mo - 40y/o

IG
<12 mo & >40 y/o
Immunocompromised & Chronic Liver Disease
can give HAV vaccine INSTEAD, if they can NOT obtain IG

36
Q

HAV Vaccine FACTS

A
  • *VERY GOOD RESPONSE**
  • *97-100%** 1st dose –> 100% after 2nd dose

do NOT need routine vaccination

Recommended in specific circumstances:
Injection Drug Users
High Prevelance of HAV

37
Q

PREVENTION of HBV

A

Mainly from SEX / BLOOD / Vertical Transmission

HBV IG = HBIG
Immunoglobulin = PASSIVE immunity

  • *HBV Vaccine**
  • *Engerix-B / Recombivax HB**
38
Q

HBV Vaccine Dosing Schedule

A

Recombivax HB or Engerix B
both have same schedule

3 DOSE REGIMEN

0 / 1 / 6-12

months

39
Q

Limitations of HBV Vaccines

Recombivax HB / Engerix-B

A

requires 3 DOSES over 6 Months

REDUCED EFFICACY in some patient populations
Diabetes:
<40 y/o = >90% effective
>70 y/o <40% effective , worse when OLDER

OBESE** / **ELDERLY** / **SMOKERS** / **Immunocompromised

40
Q
  • *HEPLISAV-B**
  • *new HBV Vaccine**

Advantages / Disadvantages

A

ONLY 2 DOSES = 0 / 1 month
Contains a ADJUVANT

BETTER EFFICACY
especially for diabetics / 40-70 / obesity / smokers

BUT it showed an:
INCREASED RISK IN ACUTE MI

41
Q

Recommendations for HBV POST-exposure
what do we need to know?

A

we have to know THE SOURCE of the HBV

  • *HBsAg POS**
  • *HBIG & Vaccine Series**

HBsAg neg / Unknown
just the HBV Vaccine series

42
Q

HBV Vaccine Dosing Schedule for INFANTS

based on what?

A

Based on Two factors:

MOTHER’s HBsAg STATUS

BIRTH WEIGHT

43
Q

HBV Vaccine Dosing for infants

Mother’s HBsAg is POSITIVE

A

REGARDLESS of WEIGHT

HBV Vaccine + HBIG
within 12 hours of birth

Test for anti-HBs @ 9-12 months

44
Q

HBV Vaccine Dosing for infants

Mother’s HBsAg is negative

A

>2kg = vaccine within 24 hours of birth

< 2kg = vaccine @day 30 or @hospital discharge

No need to Test for anti-HBs if immunocompetent

45
Q

WHO to test PRIOR to HBV Vaccination?

A

Household, sexual, or needle contacts of HBsAg + Persons

HIV Positive

Elevated LFT

M-M Sex / Inject Drugs

Immunosupressive therapy

DONORS
blood / plasma / organs / tissue /semen

46
Q

WHO & WHEN

to test AFTER HBV vaccination

A

anti-HBs @ 1-2 Months AFTER the last dose of the vaccine series

INFANTS
born to HBsAg POSitive / Unknown mother status

Health care professionals

HIV infected persons

Immunocompromised persons

Sex partners of HBsAg Positive

47
Q

TWINRIX
for what & Indication?

A

BOTH A & B
Hepatitis Vaccines

> 18 years old

PRE-exposure Prophylaxis

48
Q

Difference between

ACUTE & CHRONIC
viral hepatitis

A

CHRONIC =
> 6 MONTHS

same for all

49
Q

Recommendations for HAV

PRE-exposure

A

GIVE THESE PEOPLE HAV VACCINE!

Children @ 1 y/o

Occupational risk / M-M Sex / Inj Drug User

  • *CHRONIC LIVER DISEASE**
  • *HBV / HCV / CIRRHOTIC**

Persons w/ clotting factor disorders

Work / living / traveling to high HAV rates

50
Q

WHY do we treat HBV?

A

to REDUCE CHANCE of Developing CIRRHOSIS

& HCC

Only HEP that does NOT need to develop into cirrhotic state
to develop CANCER

51
Q

WHEN to treat HBV?

What Serological tests / Other levels

A

HBeAg = “ENVELOPE” Antigen Positive
indicates ACTIVE replication of HBV virus

Treat patients based on HIGH LEVELS of:
ALT / HBV DNA
+ Moderate to severe inflammation / fibrosis
If HBV DNA is HIGH >20k
& ALT is HIGH > 2 ULN (35 for men / 25 for women)
–> body is trying to fight it off = TREAT IT
if levels are norma = not trying to fight it = we do not treat

52
Q

WHEN to treat HBV?

If patient does NOT meet HBsAg Pos/Neg definition of treatment

A

HBsAg +POS / HBeAg -Neg

age >40 y/o

Family History of HCC

CO-Inefected w/ HIV** or **HCV

Moderate to severe fibrosis ~1mil VL

Cirrhosis w/ low VL

53
Q

Therapies for CHRONIC HBV

A

TDF** / **TAF / Entecavir
NRTI’s
TAF has less liver disease issues

pegINTERFERON

54
Q

PegINF

Positives & Negatives

A

Pegylated Interferon = HBV Treatment

positive is NO CHANCE OF RESISTANCE

Negatives = SIDE EFFECTS
PSYCHIATRIC complaints / Depression CI

+ many more & also many contraindications

55
Q

How LONG do we take HBV Treatment?

A

LIFELONG

56
Q

WHEN do we MONITOR anti-HBV Agents?

PEG-IFN

A

Liver Chemistry + CBC + HBV DNA + TSH + HBesAG/Anti-HBe
during treatment= various
Posttreatment = 12 & 24 weeks

  • *HBsAg**
  • *every 5 months**
57
Q

CONTRAIndications for IFN / PegIFN

A

Autoimmune disease

Uncontrolled Psychiatric disease

Cytopenias / Seizures

DE-COMPENSATED Cirrhosis

58
Q

Resistance in HBV Treatments

A

LONGER you treat ==> HIGHER RESISTANCE

Even HIGHER if taken ANOTHER medication in the past

INTERFERON HAS NO RESISTANCE

59
Q

Warnings for Anti-HBV Agents

A

FIRST RULE OUT HIV
before treating HBV

Ensure PATIENT COMPLIANCE
important due to –> hepatitis flare

Lactic Acidosis

  • *Bone Density / Nephrotoxicity**
  • LOWER RISK WITH TAF vs TDF*

Lamivudine has a risk for Pancreatitis

60
Q

When do we monitor NRTI’s?

A
  • *DURING TREATMENT**
  • likely on the medication FOR LIFE*

Liver chemistry / serum creatinine
every 12 weeks

HBV DNA / HBeAg / Anti-HBe
every 24 weeks

HBsAg
q 6 - 12 months

61
Q

AASLD Guideline for DURATION / Monitoring
of NRTI Treatment

HBeAg +POS+ with NO Cirrhosis

A

treatment should be continued until:
undetectable HBV DNA & persistantly normal ALT levels

at LEAST > 12 months of additional treatment
after the appearance of anti-HBe

  • if we DC the therapy we need CLOSE monitoring for RELAPSE:*
  • *every 3 MONTHS for >1 YEAR**
62
Q

AASLD Guideline for DURATION / Monitoring
​of NRTI Treatment

  • *HBeAg +POS+ chronic HBV**
  • *WITH CIRRHOSIS**
A

Patient has achieved undetectable HBV DNA level
+ Normal ALTs & Anti-HBe

STILL TREAT INDEFINITELY

63
Q

AASLD Guideline for DURATION / Monitoring
​of NRTI Treatment

ALL HBeAg -NEG- & Chronic HBV

A

NEGATIVE HBeAg but CHRONIC HEP B

TREATMENT IS STILL INDEFINITE

64
Q

Recommendations for managing HBV RESISTANCE

PREVENTION

A

AVOID unnecessary treatment

Initiate POTENT antiviral tx w/ low rate resistance

Switch therapy w/ 1* non-response

ADHERENCE

65
Q

Resistance to Adefovir

Recommendations for managing HBV RESISTANCE

A

Switch Strategy:
ENTECAVIR

Add Strategy:
typically add 2 drugs w/o cross resistance

Continue Adefovir + ADD Entacavir

66
Q

MULTI-Drug Resistance

Recommendations for managing HBV RESISTANCE

A

Switch Strategy:
TENOFOVIR

Add Strategy:
Combo of
Tenofovir + Entecavir

67
Q

Resistance to:
Lamivudine / Telbivudine / Entecavir

Recommendations for managing HBV RESISTANCE

A

Switch Strategy:
All switch to TENOFOVIR

Add Strategy:
Continue the Original drug + ADD TENOFOVIR

68
Q

Renal Adjustment for TAF / TDF?

A

Dose adjustments for everything else!

still 300mg but every 24 - 48 - 72 -96 hours

CrCl <15 = Do NOT recommend TAF

69
Q

NRTI’s & Pregnancy

A
  • *TDF =** Pregnancy class B
  • TAF = no human data yet*

Lamivudine / Entecavir = Pregnancy class C

Initiate TX if 3rd trimester w/ HBV DNA > 200k

DC DRUG @ BIRTH or <1mo post partum

70
Q

WHEN to treat CHILDREN for HBV?

A

for 2-18 y/o

ALT > 1.3x ULN
+
HBV DNA > 104 IU/mL
do not treat if normal ALT

71
Q

WHAT Agents to treat CHILDREN

with HBV?

A

High ALT + HBV DNA

Interferon
>1y/o for 24 weeks
Peg-IFN for >5y/o for HCV

  • *Lamivudine + Entacavir**
  • *>2 y/o** - same adult rec

TDF
for >12y/o for same adult rec

72
Q

Pro / Con

of NUCLEOSIDE THERAPY for HBV

A
  • *PRO**
  • *Oral / High activity**
  • low resistance w/ newer drugs*
  • *Minimal ADR**
  • *Negatives**
  • *LONG TERM** / indefinite
  • *renal toxicity rare**
  • *slower action than IFN**
  • may induce HIV*
73
Q

PRO / CON

of INTERFERON-BASED THERAPY

for HBV

A

PRO
finite duration = 48-96 weeks
NO RESISTANCE
HIGH rate of viral loss / clearance

  • *Negative**
  • *SUBQ**
  • *LOT OF ADR = PSYCHOLOGICAL**

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