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Dip GUM > Hepatitis > Flashcards

Hepatitis Flashcards

1
Q

what is the incubation period for hepatitis B

A

40 days - 160 days

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2
Q

Describe the hepatitis B virus

A

Hepatitis B is a circular, partially double stranded DNA virus. It consists of three surface antigens (HBsAg, HBeAg)

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3
Q

how can people catch Hepatitis B

A

Vertically : mother to baby
blood borne virus - needle stick injury, IVDUs sharing needles, sex, infected blood products/contaminated health care equipment (this is very rare in the UK)

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4
Q

what is the leading cause of hepatitis worldwide?

A

Hepatitis B

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5
Q

what are the consequence of chronic hepatitis B

A

HCC (hepatocellular carcinoma) and liver cirrhosis –> Acute liver failure

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6
Q

what proportion of patients with acute hepatitis B infection will be asymptomatic?

A

up to 50% of patients

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7
Q

Patients with acute hepatitis B - how many will go on to develop chronic hepatitis B (adults)

A

9/10 patients with acute hepatitis B will clear the virus without treatment. This is only true of adults.
Infants and children infected at birth - the majority will go on to develop chronic hepatitis B

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8
Q

what is the first serological marker that appears in acute hepatitis B infection

A

HBsAg

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9
Q

how is chronic hepatitis B defined serologically?

A

HBsAg presence for >= 6 months

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10
Q

A patient has Anti-HBs +ve. Does this mean they have previously had the hepatitis B vaccine or past infection? how would you investigate further

A

The presence of anti-HBs implies immunity to hepatitis B either by vaccination or previous cleared infection. In order to work this out request anti-HBc - if this is positive then implies previous cleared infection,

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11
Q

what is the difference between Anti-HBc IgM and anti- HBc IgG

A

IgM antibody is present in acute infection and over time is gradually replaced by IgG which represents past infection.

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12
Q

what does the presence of HBeAg indicate

A

HBeAg can be present in acute and chronic infection. It is a marker of infectivity and implies high HBV viral load therefore suggests high risk of transmission.

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13
Q

A patient has the following hepatitis serology, how would you define it?

HBsAg +ve, HBeAg +ve, anti-HBc IgM +ve, HBV DNA present

A

acute infection - highly infectious

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14
Q

A patient has the following hepatitis serology, how would you define it?
HBsAg +ve, HBeAg +ve, anti-HBc IgG +ve, HBV DNA high

A

chronic infection (active)

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15
Q

A patient has the following hepatitis serology, how would you define it?
HBsAg +ve, anti-HBe +ve, anti-HBc +ve (IgG), HBV dna low

A

chronic infection (inactive)

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16
Q

A patient has the following hepatitis serology, how would you define it?

Anti-HBs +ve, Anti-HBc (IgG +ve), anti-HBe +ve
HBV DNA -ve

A

Immunity, following acute infection

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17
Q

A patient has the following hepatitis serology, how would you define it?
Anti-HBs +ve

A

Immunity following vaccination

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18
Q

How would you counsel a patient when informing them of a positive hepatitis B serology blood test - HBsAg +ve, anti-HBc +ve IgM, HBeAg +ve

A

These results imply they have acute hepatitis B infection.
check their understanding
explain that hepatitis means inflammation of the liver.
There are lots of different causes of inflammation to the liver; can be due to infective causes, alcohol or drugs and other diseases. Hepatitis B is a viral infection that lives in the blood. It is transmitted in different ways including from mum - to baby at the time of delivery, sharing of needles, occupational exposure e.g. sharps injury, through sexual contact.
hepatitis B can be defined as either acute or chronic. 90% of adults that acquire hepatitis B infection will clear the virus themselves. the remaining 10% can develop chronic infection. it is important we monitor the virus as chronic hepatitis B infection can lead to scarring and permanent damage of the liver. This is what we call cirrhosis. Overtime this increases your risk of developing HCC (liver cancer).

What we need to do today are further investigations - specifically bloods to check how your liver is working (LFTs), a marker to check for Liver cancer (AFP), STI screen and chic for other types of hepatitis and immunity to hepatitis A ( HIV, STS, hepatitis A antibody, hepatitis C and D), imaging - USS and a special type of scan called a fibroscan to check for scarring of the liver.

We will refer you to a liver specialist.

In the meantime things you can do to prevent onward transmission to partners and close contacts:
1. avoid sharing razors, toothbrushes
2. don’t donate blood/semen/ organs until told not infectious
3. PN - disclosure to partners, no sex until partners fully vaccinated and confirmed immunity
4. cover up any cuts and grazes
5. clean any blood spillages
6. reduce alcohol intake/abstain to prevent liver cirrhosis
-

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19
Q

once a patients serology confirms hepatitis B what other investigations do you need to do to investigate further?

A

Hepatitis A antibody (immunity), hepatitis C, hepatitis D
HIV blood test +/- STI screen
AFP
imaging - liver USS + fibroscan

refer to hepatology clinic

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20
Q

what percentage of babies born from mothers with hepatitis B infection will acquire hepatitis B

A

up to 90% will acquire hepatitis B

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21
Q

Children vertically infected with hepatitis B; what percentage will clear the virus and what percentage go on to develop chronic hepatitis B?

A

90% of children infected with hepatitis B will develop chronic hepatitis B; only 10% of children clear the virus

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22
Q

The aim of hepatitis B treatment is to achieve cure? T/F

A

False there is no cure for hepatitis B - treatment works to try and suppress the virus and prevent cirrhosis of the liver

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23
Q

A patient is diagnosed with acute hepatitis B infection. He informs you he has a wife and they had sex 2 days ago. How would you manage this situation?

A

Get the wife into clinic urgently - screen for HBsAg, anti-HBs, anti-HBc
discuss with virology as need to consider HBIG 500 I.U IM - this can be given ideally < 12 hours post exposure, but up to 7 days.
If no immunity and no evidence of acute hepatitis B - give HBIG and also provide super accelerated hep B vaccine (0, 7, 21 days and booster at 12 months) - check anti-HBs following third dose of the vaccine
avoid sex until anti- HBs > 10

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24
Q

when would you consider treating a patient with known hepatitis B infection?

A
  • deranged LFTs - rising ALT
  • high HBV DNA
  • evidence of cirrhosis and scarring on USS/fibroscan
  • deranged clotting
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25
Q

when would you consider treating a pregnant lady with hepatitis B

A
  • consider treating a pregnant lady in the third trimester if high levels of HBV DNA >10*7 to reduce vertical transmission
  • on delivery: screen the baby, give hep b vaccine +/- HBIG
    -consider Rx with monotherapy tenofovir
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26
Q

What HBV viral load is treatment of hepatitis B usually considered in a/s with liver cirrhosis?

A

HBV viral load > 2000 IU/ml + evidence of inflammation/fibrosis of the liver

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27
Q

prior to commencing anti-viral Rx of hepatitis B what other blood borne virus is it essential to test for and what is the reason for this?

A

essential to test for HIV
this is because anti-viral medications used to treat HBV are also Rx options for HIV and if unknown can lead to mutations in HIV which can lead to resistance causing difficulty in treatment options

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28
Q

if someone presents as a contact of hepatitis B and is not vaccinated to hep B or a non responder to hep B vaccine what time frame should HBIG be administered

A

have to check with virology before giving HBIG (human recombinant hep b immunoglobulin)

works best if given within 12 hours of exposure, ideally give within 48 hours, no use after 7 days after exposure

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29
Q

if someone presents as a contact of hepatitis B and is not vaccinated to hep B or a non responder to hep B vaccine what should you do?

A
  1. check patients bloods for HbS Ag, HbS Ab.
  2. need to verify source as only need HBIG if acutely infected or recent diagnosis of chronic hep b - check with virology.
  3. whilst gathering this information then give Hep B vaccine (not a live vaccine, so can be given to pregnant patients). offer super accelerated (0,7,21 days and dose at 12 months) or accelerated 0,1,2 months and dose at 12 months.
  4. Avoid sexual contact, especially unprotected penetrative sex, until vaccination has been successful (anti-HBs titres >10I.U./l.)
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30
Q

if someone presents as a contact of hepatitis B and has been vaccinated against hep B what should you do?

A

check serology, whist doing this offer booster dose

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31
Q

who should we screen for hepatitis B infection in sexual health:

A
  1. HIV positive patients
  2. MSMs
  3. CSW
  4. patients from endemic countries
  5. patients having sex with partners from endemic countries
  6. SA
  7. PWID or partners of PWID
  8. occupational exposure - needle stick injury
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32
Q

what is the ideal screening tests for hepatitis B according to BASHH guidelines

A

Hepatitis B surface antigen and hepatitis B core antibody.

(in Sheffield we do hepatitis b surface antigen and hepatitis B surface antibody but potentially missing people previously cleared hep B)

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33
Q

what type of vaccine schedule should be considered for at risk groups and why?

A

super accelerated: 0,7,21 days and 12 months

evidence suggests better adherence, need to get three vaccines in total in order to provide immunity in at risk groups

34
Q

how long is immunity thought to last following monovalent vaccination with hepatitis B

A

> 20 years

35
Q

what happens to vaccine response in patients with HIV co-infection

A

response rate to vaccination is less and immunity wains quicker

36
Q

what are the three vaccine schedules for hepatitis B

A
  1. super accelerated: 0,7,21 days and 12 months
  2. accelerated: 0,1,2 months and 12 months
    3.standard schedule: 0,1,6 months
37
Q

what is the benefit of a standard hep b vaccine schedule compared to super accelerated or accelerated

A

standard hep b vaccine provides higher surface antibody titres at 7 months compared to super-accelerated and accelerated

38
Q

what does vaccine response rate depend upon in HIV co-infected patients

A

dependent upon CD4 count not ART (although would expect better CD4 counts in patients on ART!)

higher CD4 count, better response to Hep b vaccine

39
Q

what is the vaccine schedule for hepatitis B in patients co-infected with HIV

A

0,1,2,6 months - double dose engerix (40 rather than 20mcg) or Fendrix 20

40
Q

what is hep B vaccine response increased by if double dose in HIV positive patients

A

increases by 13%

41
Q

how many different genotypes are there to hepatitis B

a) 4
b) 6
c) 8
d) 12

A

c) 8

42
Q

at what point should you check antibody response to hep b vaccine

A

4-12 weeks post completion of primary course (bash states, greenbook states 1-2 months post course)

43
Q

if HbSAb> 100 what does this suggest

A

immunity no further doses required

44
Q

if HbSAB 10-100 what does this suggest what would you do?

A

suggests patient has got some immunity, probably enough if they were exposed to hepatitis B

give booster and no further antibody tests

45
Q

if HbSaB < 10 what does this suggest if vaccinated as an adult

A

suggests non-responder, check reason for non response is not acute hep B infection.

repeat full course and then check antibody response 4-12 weeks after completion. If still <10 then consider non responder and will need HBIG if exposed.

46
Q

what are some of the treatment options for chronic hep B infection

A

TDF/ TAF/ pegylated interferon/ entecavir

47
Q

what % of babies born to mothers become infected with hepatitis B if Hepatitis e antigen positive

a) 10%
b) 30%
c) 50%
d) 90%

A

90%

48
Q

what % of babies born to mothers become infected with hepatitis B if Hepatitis e antigen negative, hepatitis B surface antigen positive

a) 10%
b) 30%
c) 50%
d) 90%

A

10%

49
Q

hepatitis B is a: -

a) single stranded DNA virus
b) partially double stranded DNA virus
c) double stranded DNA virus
d) single stranded RNA virus
e) double stranded RNA virus

A

b) partially stranded DNA virus

50
Q

hepatitis C is a:-

a) single stranded DNA virus
b) partially double stranded DNA virus
c) double stranded DNA virus
d) single stranded RNA virus
e) double stranded RNA virus

A

d) single stranded RNA virus (positive)

51
Q

what family of virus does hepatitis B belong too?

a) hepadnaviridae
b) flaviviridae
c) picorna virus

A

Hepadnaviridae

52
Q

what family of virus does hepatitis c belong too?

a) hepadnaviridae
b) flaviviridae

A

b) faviviridae

53
Q

which is more likely to be transmitted to baby hepatitis B or C due to vertical transmission

A

hepatitis B

54
Q

what type of transmission is responsible for majority of hepatitis C infection

a) vertical
b) sexual
c) parental
d) occupational

A

c) parental spread - through shared needles/syringes

55
Q

who should we screen for hepatitis C in?

A

a) HIV positive, hep A/B or D positive
b) MSMs
c) CSW
d) Sexual assault victims
e) patients from endemic countries
f) PWID and partners of PWID
g) people with partners from high risk areas

56
Q

what is the incubation period for hepatitis C

A

4 - 20 weeks

57
Q

what genotypes of HCV account for the majority (90%) of hepatitis C infection

a) 1 and 2
b) 2 and 3
c) 1 and 3
d) 1 and 4

A

c) 1 and 3

58
Q

what serology should you do if you suspect someone has hepatitis C

A

hep c antibody (90% positive by 3 months), if suspected hep C then hep c viral RNA (positive as quickly as 2 weeks post exposure )

59
Q

what is the aim of hepatitis C treatment? (SBA)

a) reduce inflammation and prevent HCC
b) cure
c) prevent cirrhosis

A

b) cure! (unlike hep b where answer would be a)

60
Q

how is hepatitis C cure defined?

a) Hepatits C viral RNA negative at 8 weeks
b) hepatitis C viral DNA negative at 8 weeks
c) Hepatits C viral RNA negative at 12 weeks
d) hepatits C viral DNA negative at 12 weeks

A

c) hepatitis viral RNA negative at 12 weeks

61
Q

can patients clear hepatitis C virus

A

yes - ideally monitor patients and complex algorithm that decides whether or not to offer Rx to hepatitis c during acute phase. Usually all patients offered hep c Rx in chronic hep C

62
Q

how is chronic hep C defined

A

hep C viral RNA present for > 6 months

63
Q

what class of drugs are used in treatment of hepatitis C

A

DAA (direct acting anti-viral agents)

64
Q

what is the main MOA of DAAs used in management of hepatitis C

A

interfere with non structural proteins within hepatitis C virus then prevent RNA replication,

65
Q

do we treat hepatitis C during pregnancy and why?

A

no - ribavirin is teratogenic

66
Q

how often should we screen MSM patients and HIV positive patients at risk of acquiring hep c infection?

A

annually

67
Q

what family of virus does hepatitis A belong to?

a) hepadnaviridae
b) flaviviridae
c) picorna virus

A

c) picorna virus

68
Q

hepatitis A is a: -

a) single stranded DNA virus
b) partially double stranded DNA virus
c) double stranded DNA virus
d) single stranded RNA virus
e) double stranded RNA virus

A

d) single stranded RNA virus

69
Q

hepatitis E is a:-

a) single stranded DNA virus
b) partially double stranded DNA virus
c) double stranded DNA virus
d) single stranded RNA virus
e) double stranded RNA virus

A

d) single stranded RNA virus

70
Q

out of hepatitis A-E which is the only virus that is a DNA virus?

A

hepatitis B is a double stranded DNA virus.

whereas hepatitis A, C, D and E are all single stranded RNA virus

all are positive viruses except for hepatitis D which is negative

71
Q

how is hepatitis A transmitted

A

fecal - oral route of ingestion of contaminated food and water or by direct contact with an infection individual

sexually transmitted through oral sex/ rimming etc

72
Q

what population are particularly susceptible to sexual transmission of hepatitis A and how can we prevent infection?

A

MSMs, hepatitis A vaccination

73
Q

what is the infectious period for hepatitis A and which group of patients can be more ‘infectious’

A

2 weeks before the onset of jaundice and up to 1 week following resolution of symptoms.

HIV patients co-infected with hepatitis A can be more infectious but they are not at increased risk of acquiring hepatitis A

74
Q

what is incubation period of hep A

A

15-45 days, average 28 days

75
Q

if someone presents with symptoms suggestive of hepatitis A how would you test

A

hepatitis A - IgM

76
Q

if you diagnose hepatitis A - E which agency should you notify

A

UKHSA - is a notifiable disease

77
Q

how would you manage someone with acute hepatitis A

A

if severely unwell - admit
otherwise mainly supportive management - hydration, rest, analgesia

78
Q

other than supportive care and informing UKHSA what is another important consideration for patients with hepatitis A infection?

A

employment history - need to avoid food handling 2 weeks prior to onset of jaundice and until 1 week post symptom resolution

also PN and no sex until symptoms resolved.

79
Q

what options do we have for PEP in terms of PN for hepatitis A

A

hepatitis A HNIG and/or hepatitis A vaccine

80
Q

what are the vaccine options for hepatitis A

A

monovalent vaccine for hepatitis A: single dose immediately and booster at 6-12 months (2 doses)

bivalent vaccine (hep a and b): 0,1 and 6 months

81
Q

how long does vaccination against hepatitis A last

A

95% protection for at least 10 years, increasing evidence immunity may last > 20 years and potentially lifelong.

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