Hep A & B Flashcards
- RNA virus Picornavirdae Family
- Acute, self limiting, low fatality rate
- Confers lifelong immunity
Hep A
Hep A
- Transmission? (2)
- Treatment?
- Fecal-oral route
- Ingestion - contaminated water/foods prepared using water
-
Tx: supportive care
- Immune globulin
- Handwashing hygiene
- Prevention w/ vaccination is preferred!
- NO ROLE FOR ANTIVIRAL agents!!
Hep A Vaccine
- Start schedule at what age?
The ____ of vaccines changes at age ___, but the ____ is the same - What vaccine is only for adults?
- 1 year old
- dose / 19 y/o / schedule of administration (0, 6-18 months)
- TWINRIX*
4 ADEs of the Hep A vaccine
- Soreness / warmth at injection site
- HA
- Malaise
- Pain
Efficacy of Hep A vaccine is decreased in which 2 scenarios?
- HIV pts w/ CD4 counts <200
-
Co-infected HIV/HCV pts
- HCV = hep C virus
When does the Hep A pre-exposure prophylaxis vaccine need to be given prior to departure to endemic areas?
- Vaccine can be given regardless of schedule dates of departure
-
If pt is older, immunocompromised, or has hx of chronic liver disease, or other chronic medical condition: If the patient is traveling within 2 weeks then give BOTH Ig and Vaccine
- IG=passive coverage
- Vaccine= active coverage
What is the Post-exposure prophylaxis for Hep A?
- Administer either Vaccine or IG
What is the concern for the vaccine as post-exposure prophylaxis?
Uncertain efficacy in adults older than 40 years or with underlying conditions
Hep A - Post-Exposure Prophylaxis
- Vaccine brands are interchangeable for _____.
booster shots
Hep A
- ___ for pre and post exposure when vaccine is not an option
IG
Hep A Pre/Post exposure
- Recall that with recent ___ exposure, post-exposure prophylaxis with _____ is preferred.
HAV / vaccine
Hep A Pre/Post exposure
- Pts who receive at least 1 dose of the HAV vaccine at least ___ prior to exposure do NOT need pre-exposure or post-exposure prophylaxis w/ IG
1 month
Hep A Pre/Post exposure
- IG is indicated when vaccination is NOT an option
- IG prophylaxis is preferred in 5 cases?
- <12 months or >40 years
- Immunocompromised
- Chronic liver disease
- Underlying medical conditions
- When vaccine contraindicated
Hep A
- Vaccine confers ____ immunity
- Immunoglobulin confers ____ immunity.
- Vaccine: active
- IG: passive
Preparation of concentrated antibodies against HAV
- 85% reduction in infectivity & moderation of infection if given within the first ___ weeks of infection
- Anaphylaxis has been reported in pts w/ ___ deficiency
- 2 weeks
- IgA
Dosing of Hep A pre/post exposure
- Post-exposure prophylaxis and for short term pre-exposure coverage is for <__ months. Dose =0.02
- Long term pre-exposure prophylaxis of < or = ___ months. Dose =0.06 (dose is tripled for longer exposure)
- 3 months
- 5 months
Administration sites for Hep A pre/post exposure
- Older than 24 months use which 2 muscles?
- Younger than 24 months use which muscle?
- >24 months: deltoid or gluteal
- <24 months: anterolateral thigh muscle
Hep B
- How many genotypes? US?
Transmission? - Highly infectios (50-100x more infectious than HIV)
- Stable in environment for at least __ days
- Incubation for both acute & chronic infections?
*
- 10, US-G
- sexually, parenterally, perinatally (present in saliva, semen, vaginal excretions)
- 7
- 6 weeks to 6 months
What is the most predictive factor for developing a chronic infection of Hep B?
Age
- Perinatal (100% immune tolerance to virus)
- Infants & children (30%) are at high risk for chronic infection
- Adults <5%
- Hep B leads to an increased risk for what 2 conditions?
- Which sex is more at risk?
- Cirrhosis
- Hepatocellular carcinoma
- Men
T/F
- Hep B virus itself does not seem to be pathogenic to cells
- Immune response to the virus is cytotoxic to _____
True
- hepatocytes
______ is critical to viral clearance of Hep B
- Suppress HBV replication, prevents disease progression to cirrhosis and HCC
- Loss of HBsAg
- Confers _____
- Loss of HBeAg
- Confers _____
The immune response
- HBsAg: immunity & clearance
- HBeAg: infection resolved
Patients who continue to have detectable HBsAg for more than __ months have chronic HBV.
- Infections can be controlled, cure is NOT possible bc/ HBV template is integrated into the ______.
- 6
- host genome
What is the “acute supportive” tx of Hep B?
Immune Globulin (IVIG) for acute exposure
What is the prevention for Hep B?
- Vaccine at 0, 1, and 6 months
- Serology marker anti-HBsAg only (Anti HBs)
2 things for Chronic Management of Hep B
- Interferons
- Antivirals
- What is the vaccine schedule of Hep B for adults?
- What are the 2 names of the vaccines?
- 1 mL IM at 0, 1, & 6 months (3 doses)
- Engerix-B
- Recombivax HB
Hep B Vaccine for infants
- Amount?
- Doses / Schedule?
- 2 vaccines names?
- 0.5 mL/dose
- 3 doses at 0, 1, & 6 months
- Engerix-B
- Recombivax HB
What do the combination vaccines for infants for Hep B contain?
- Hep B
- DTaP
- HIB
(**Should not be used for the “birth” dose of Hep B, but may be used to complete the course beginning after the infant is 6 weeks old or greater**)
–> DTaP and HIB are given at 2 months old
Newborn first dose depends on the ____ status of the mother
HBsAG
Infants w/ HBsAg ____ mothers
- first dose: 0.5 mL at birth or before discharge (may be delayed in certain cases)
negative
Infants w/ HBsAg ____ mothers:
- 1st dose: 0.5 mL *within first 12 hours of life*, even if premature and regardless of birth weight
- Hepatitis immune globulin should be administered at the same time at a different site
Positive
Infants with mother’s HBsAg status ____
- 1st dose: 0.5 mL *within 12 hours of birth* even if premature and regardless of birth weight
Unknown
Serologic testing and revaccination may be necessary in patients w/ ______.
- Serologic testing is recommended __ - __ months after the final dose of the primary vaccine series & ____ to determine the need for booster doses
renal impairment
- 1 -2
- annually
Serologic Testing & Revaccination for Hep B
- Persons w/ anti-HBs concentrations of <___ should be revaccinated with __ doses of the vaccine
- 10 mIU/mL
- 3 doses
What adjustment is needed for hepatic impairment for serologic testing w/ Hep B?
No adjustment needed
Hypersensitivity to which 3 things w/ Hep B?
- Yeast
- Hep B vaccine
- any component of the formulation
Syncope associated w Hep B vaccine
- reported w/ injectable vaccines
- May be accompanied by which 3 sxs?
- transient visual disturbances
- weakness
- tonic-clonic movements
What are the 5 dermatologic ADEs from Hep B vaccine?
- Angioedema
- Petechiae
- Pruritis
- Rash
- Urticaria
What may diminish the therapeutic effect of Hep B vaccines (inactivated)?
Immunosuppressants
Hep B Vaccines should be given __ inches apart or in separate arms.
2
Treatment of Hep B may require ___ therapy w/ resistance as a concern.
- Post - exposure within __ days
- Hep B Immunoglobulin
- Adult: .06ml/kg IM
- Follow with HBV
- Long Term Therapy
- 7
What is the treatment for Chronic Hep B?
- Immunomodulating agent: PEG-INF alpha (PegaSys) (interferon)
-
Antivirals:
- Lamivudine
- Adefovir
- Entecovir***
- Telbivudine
- Tenofovir***
- Vaccinate against HAV
- Long term Hep B therapy may require long term therapy which has the potential for developing ____.
Resistance
Long Term Hep B Therapy
- Resistance to ____ and _____ is most common!
- Resistance to ___ and ____ can occur…
- Less resistance to ______ (=
- Optimal tx of resistant strains is _____
- MC: lamivudine & Telbivudine
- Can occur: Adefovir & Entecavir
- Least: Tenofovir
- Unknown
Recommendations for pts w/ Hep B
- Vaccinate ____ and ____ contacts
- Avoid _____
- what other atypical tx option?
- sexual & household
- alcohol
-
milk thistle
- (protective & restores liver hepatocytes, not replicated in western medicine. GOOD evidence of being hepatoprotective)
- Also not replicated & has good evidence: horse chestnut given for HF
What 2 circumstances of Chronic Hep B require immediate treatment?
- Jaundice
- Decompensation
Suggested management algorithm based on AASLD for chronic Hep B pts w/ CIRRHOSIS?
-
If ALT <2 or less than ULN
- –> observe
-
If ALT >2
- Initial tx: IFN, PEG - IFN, Entecavir, or Tenofovir
- Immediate tx if jaundice or decompensation
Goal of Hep B Tx
- Hepatic damage is sustained by _____
- Drug therapy suppresses viral replication by either ____ or ____ (the nucleoside agents - NAs)
- ongoing viral replication
- immunomodulating agents / antivirals
Tx of Chronic Hep B**
ADE:
- HA, fatigue, upper abd pain
- lactic acidosis
Entecavir
Tx of Chronic Hep B**
ADE:
- Nausea, abd pain, diarrhea
- dizziness, nephropathy
- lactic acidosis
Tenofovir disoproxil
Tx of Chronic Hep B**
ADE:
- Flu-like sxs
- fatigue
- mood disturbances** (depression)
- Cytopenias
- Autoimmune disorders
Pegylated interferon alfa-2a
What is almost a guaranteed ADE of Pegylated interferon alfa-2a?
Depression, so start antidepressants before giving interferon.
