CD - Hep B-part 2, Hep C

Question 1

is there a treatment for Hep B (1)

Answer 1

1- no cure

Question 2

are there medications that can reduce morbidity from hep B (1)

Answer 2

1- yes - antivirals and immunomodulators can reduce viral replication and thus reduce liver damage in chronic infection

Question 3

what is the schedule for hep B vaccine (1)

Answer 3

1- not age-dependent per se:
3 doses at 0, 1 and 6 months (month 0 = first dose)

Question 4

are booster doses required for hep B vaccine in immunocompetent people (1)

Answer 4

1- no

Question 5

are booster doses required for hep B vaccine in those at high risk of HBV infection/complications (1)

Answer 5

1- high-risk people who do not develop anti-HBs titre of at least 10 IU/L after the
initial HB vaccine series should receive a second
HBV vaccine series

Question 6

what is the effectiveness of hep B vaccine (1)

Answer 6

1- 95-100% effective in preventing chronic infection

Question 7

how long is the hep B vaccine effective for (1)

Answer 7

1- protection against chronic disease lasts for at least 30 years following immunization - I.e. protection can last for decades

Question 8

Within what timeframe do you get post-immunization serologic testing (anti-HBs titre) (1)

Answer 8

1- within 1-6 months after completion of vaccine series, for recommended groups

Question 9

what are the groups recommended to get post-imm serologic testing (anti-HBs) titre -

‘medical condition’ - 5
‘contacts’ - 2
‘occupational’ - 1

(8)

Answer 9

1- immunocompromised people
2- those on dialysis or with chronic renal disease
3- advanced liver disease
4- solid organ transplant candidates and recipients
5- pregnant women at high risk of HBV infection
6- those with potential exposure (percutaneous, mucosal)
7- sexual and household contacts of acute cases and chronic carriers of HBV
8- workers who need confirmation of immunity due to potential for occupational exposure

Question 10

in individuals who meet the groups recommended to get HBV post-imm serology, how long should titres be delayed from being collected if the person received HBIg PEP (1)

Answer 10

1- anti-HBs titre should be delayed for 6 months post HBIg PEP

Question 11

what would an infant HBV vaccination program be most effective at reducing (1)

Answer 11

1- number of chronic carriers

Question 12

why would an infant HBV vaccination program be effective at reducing the number of chronic carriers (2)

Answer 12

1- 90% of infants infected with HBV go on to develop cirrhosis i.e. chronic infection
2- despite targeted imms for infants born to HBV+ moms, some infants are missed and acquire HBV - universal infant program would prevent these cases

Question 13

what would an adolescent HBV vaccination program be most effective at reducing (1)

Answer 13

1- number of acute infections

Question 14

why would an adolescent HBV vaccination program be effective at reducing the number of acute infections (2)

Answer 14

1- most acute HBV cases occur in adolescents/adults
2- there often is a rapid drop in antibodies for the first year, so adolescents will have maximum protection at time of greatest risk if vaccine given in adolescence

Question 15

what is an anamnestic reaction (1)

Answer 15

1- renewed rapid production of an antibody following second or later contact with the original provoking antigen/related antigens

Question 16

what is a caveat with an adolescent HBV vaccine program that is more in favour of an infant program (1)

Answer 16

1- around 90% of 18-year olds will mount an anamnestic response after a primary infant series…so it might make more sense to do an infant program to hit both chronic carrier/acute infection numbers

Question 17

in general, what is the landscape in Canada of HBV vaccination programs in terms of routine infant vs. adolescent programs (1a) and for high-risk infants (1b)

Answer 17

1a- inconsistent across the country - roughly half the provinces have infant program, the other half have adolescent program
1b- all provinces have programs for high-risk infants

Question 18

HBV case management: what education on safe sex should you provide (1)

Answer 18

1- acute cases should abstain from sex OR practice safer sex until contacts have been appropriately screened and immunized

Question 19

HBV case management: what kind of clinical mgmt do cases need (2)

Answer 19

1- test for other STIs and HIV
2- carriers to be linked with appropriate other services based on morbidity

Question 20

HBV case management: what is guidance re: blood donation for cases (1)

Answer 20

1- acute cases and carriers of HBV cannot donate blood - cannot donate if you’ve ever tested positive for HBV

Question 21

HBV contact mgmt: who would be considered HBV contact (4)

Answer 21

1- household contact of acute case/carrier
2- sexual contact of case/carrier
3- percutaneous or mucosal exposure to blood/bodily fluids potentially containing HBV (e.g. razor, toothbrush)
4- infants born to HBV+ mother

Question 22

HBV contact mgmt: what is PEP for non-sexual household contacts (1)

Answer 22

1-
HBV vaccine ONLY (no HBIg)

Question 23

HBV contact mgmt: what is the timeline for offering immunoprophylaxis as part of PEP (2)

Answer 23

1-
within 7 days of a percutaneous/mucosal exposure
2-
within 14 days of sexual exposure

Question 24

HBV contact mgmt: what is the timeline for offering immunoglobulin as part of PEP (1)

Answer 24

1-
within 48h of exposure but up to 7 days of perc/mucosal exposure, or up to 14 days of sexual exposure

Question 25

HBV contact mgmt: what is PEP for sexual household contacts (2)

Answer 25

1- HBV vaccine
2- HBIg

Question 26

HBV contact mgmt: what is PEP for percutaneous/mucosal exposure (2)

Answer 26

1- HBV vaccine
2- HBIg

Question 27

HBV contact mgmt: what is PEP for infants born to HBV+ mother (2)

Answer 27

1- HBV vaccine
2- HBIg

Question 28

what is the agent for hepatitis C (1)

Answer 28

1- hepatitis C virus (HCV)

Question 29

what are risk factors for hep C virus acquisition -

SDoH - 5
Nosocomial/medical condition - 3
Lifestyle/travel - 3

(11)

Answer 29

1- current/hx of IVDU
2- hx of incarceration
3- those who are marginally housed
4- high-risk sexual behaviours with HCV+ person
5- intranasal/inhalational drug use with HCV+ person
6- received healthcare when no universal precautions (e.g. non-sterile equipment)
7- received blood products/transfusion, organ transplant before 1992 in Canada
8- hemodialysis
9- born, travelled or resided in HCV-endemic countries
10- those who have had needle-stick injuries
11- tattooing/piercing/sharing sharp (personal hygiene) instruments with HCV+ person

Question 30

what is the reservoir for HCV (1)

Answer 30

1- humans

Question 31

what is the mode of transmission for HCV (1, and 2 less likely)

Answer 31

1- blood-borne (e.g. needles, transfusion)
2- sexual/vertical transmission less likely

Question 32

what is the incubation period for HCV - range (1)

Answer 32

1- range: 2 weeks to 6 months

Question 33

what is the period of communicability for HCV (1)

Answer 33

1-
1-2 weeks after exposure, may persist indefinitely in chronic carriers

Question 34

can HCV cases be asymptomatic (1)

Answer 34

1- YES - 20-30% of cases are asymptomatic

Question 35

if symptomatic, what is the clinical presentation of HCV infection - JAFNA (5)

Answer 35

SLOW, GRADUAL ONSET OF
1- jaundice
2- anorexia
3- fatigue
4- nausea/vomiting
5- abdominal pain

Question 36

what is the clinical outcome if acute HCV infection goes without treatment (1)

Answer 36

1- 75-85% of acute infections will become chronic and can lead to cirrhosis, liver failure, hepatocellular carcinoma

Question 37

what does HCV RNA indicate as a test (1)

Answer 37

1- measure of viral load and detectable only during active infection (not with past/resolved infections)

Question 38

what does anti-HCV antibody indicate as a test (1)

Answer 38

1- is positive in current and past infections, including resolved infections

Question 39

is there a treatment for hep C (1) and how does it compare to older treatments (1)

Answer 39

1- yes - direct-acting antiviral (DAA) tablets achieve permanent cure in > 90% of cases
2- fewer side-effects and shorter treatment regimens with DAAs than interferon (defunct) and ribavirin

Question 40

HCV case management: what do you do for case investigation (3)

Answer 40

1- determine risk factors
2- determine possible source of infection
3- test anti-HCV-positive people for HCV RNA

Question 41

HCV case management: can a HCV case (past or present) donate blood

Answer 41

1- NO do not donate blood or blood products

Question 42

HCV case management: what vaccines should HCV cases receive (1)

Answer 42

1- publicly-funded Hep A and B vaccines for those with chronic liver disease including those with hepatitis (consult provincial immunization manual)

Question 43

HCV contact mgmt: when is contact notification recommended (1)

Answer 43

1- notify contacts for cases whose HCV RNA status is positive or unknown, and contacts meet defined criteria (see groups)

Question 44

HCV contact mgmt: what are groups who would be considered contacts (3)

Answer 44

1- those who have shared drug equipment with a case
2- those who have shared personal-use items with a case (e.g. razor, toothbrush)
3- sexual partners with high-risk sexual behaviour, blood-to-blood contact, long term partners

Question 45

HCV contact mgmt: what is the timeframe to conduct contact follow-up (1)

Answer 45

1- outer limit to identify contacts is onset of risky behaviour, or previous negative antibody result (whichever is more recent)

Question 46

screening for hep C (hot topic) - what is the guidance from CASL (Canadian association for the study of the liver) (1)

Answer 46

1- 2018 guideline recommends targeted screening in those at high risk, and also those born from 1945 to 1975

Question 47

screening for hep C (hot topic) - what is the guidance from CTFPHC (Canadian task force) (1)

Answer 47

1- 2017 guideline recommends against screening for HCV in adults who are not at elevated risk