Hepatitis Flashcards
What is % response to ultra rapid Hep B vaccination course?
HebBsab response in 80% at 4-12 weeks post course
Can offer 3 further doses to other 20% but most would eventually respond
Response increases to 95% with booster
What is the ultra rapid Hepatitis B vaccine schedule?
0, 7 days, 21 days
Booster at 12 months
What is the rapid (post exposure) Hepatitis B vaccine schedule?
0, 1 m, 2m
Booster at 12 m
What is the standard Hepatitis B vaccine schedule?
0, 1m, 6m
Booster 12m
What are some of the associated factors for increased risk of hepatitis C?
Presence of other STIs (particularly syphilis and LGV
Traumatic anal sex
Fisting
shared sex toys
group sex, serosorting
Concomitant use of recreational drugs (including injected recreational drugs such as crystal methamphetamine in ‘chem-sex’ party settings).
How often should hepatitis C be tested for in MSM
Hepatitis C testing should be offered at least annually to men eligible for three-monthly HIV testing and those taking or eligible for PrEP
HIV-positive MSM should be routinely screened for HCV at least annually
Causes of raised bilirubin?
Normal levels are 3-17
Jaundice- levels over 40
Obstructive liver disease (usually also raised ALP and GGT)
Gilbert’s disease
Haemolysis
Atazanavir
What is the risk of vertical transmission in Hepatitis B?
90% of pregnancies where the mother is hepatitis B e antigen positive
10% of surface antigen positive, e antigen negative mothers.
Most (>90%) infected infants become chronic carriers
What can be done to prevent hep b infection to babies born to Hep B positive mums?
Infants born to infectious mothers are vaccinated from birth.
Hepatitis B specific Immunoglobulin 200 i.u. IM is also given in certain situations where the mother is highly infectious
This reduces vertical transmission by 90%.
Can Hep B positive Mum be treated in pregnancy to reduce the risk of transmission?
Tenofovir monotherapy can be considered for pregnant women with HBV DNA >107 IU/ml in the third trimester
Can Hep B positive Mum breastfeed?
Yes
% of MSM needed to vaccinate against Hepatitis A to prevent an outbreak?
70%
Diagnosis? HBsAg + HBeAg + Anti HBc IgM + Anti HBc IgG + HBV DNA + HBeAb - HBsAb -
Acute Hepatitis B
Diagnosis? HBsAg + HBeAg - Anti HBc IgM + Anti HBc IgG + HBV DNA - HBeAb + HBsAb -
Resolving Hepatitis B infection
Diagnosis? HBsAg + HBeAg + Anti HBc IgM - Anti HBc IgG + HBV DNA + HBeAb - HBsAb -
Chronic
Highly infectious Hepatitis B
Diagnosis? HBsAg + HBeAg - Anti HBc IgM - Anti HBc IgG + HBV DNA + HBeAb + HBsAb -
Chronic Hepatitis B
Low infectivity
Diagnosis? HBsAg - HBeAg - Anti HBc IgM - Anti HBc IgG + HBV DNA - HBeAb + HBsAb +
Resolved immune Hepatitis B
Diagnosis? HBsAg - HBeAg - Anti HBc IgM - Anti HBc IgG - HBV DNA - HBeAb - HBsAb +
Hepatitis B vaccination
How is Hepatitis C transmitted in pregnancy?
It is thought that hepatitis C is transmitted via the placenta rather than through the birth canal.
Risk of vertical transmission of hepatitis C
LOW RATE
~5% (7% if HIV coinfection)
Incubation of hepatitis c?
4-20 weeks (1-5 months)
What % of people with hepatitis C infection become chronically infected?
80%
How many with acute hepatitis C have symptoms?
20%
How many people with hepatitis C go on to develop cirrhosis?
10-20% after 20- 30 years
What is the annual rate of developing HCC in patient with hep c cirrhosis?
1-5%
What is the most common genotype in hepatitis C in UK?
Genotype 1
G1 (more common blood
G3- IV drug use)
How long until hepatitis C antibody becomes positive?
3 months
If recent exposure can do RNA
Why might someone not develop a HCV antibody?
If they have HIV or are immunosuppressed
What findings on fibroscan might indicate fibrosis or cirrhosis?
> 9.6 kpa- fibrosis
14 kpa- cirrhosis
(metavir scores)
What advice for MSM who have chronic hepatitis C?
condoms gloves for fisting avoid lube/group sex Single person sex toys advise disclosure
Length of duration for hepatitis C DAA?
8-12 weeks
Types of HCV drugs?
NS3/4a inhibitors- PREVIR
NS5A inhibitors- SVIR
NS5B inhibitors- BUVIR
What type of virus is hepatitis C?
single stranded RNA
Other causes of hepatitis?
Viral hepatitis Autoimmune Haemochromatosis Syphilis EBV/CMV
what type of virus is hepatitis B
Double stranded DNA
How many genotypes does Hepatitis B have?
A-F (6)
Incubation of hepatitis b?
1-6 months
Definition of chronic hepatitis b?
> 6/12 HBsAg positivity
How many with Hepatitis B get cirrhosis?
8-20% over 5 years
How many with hepatitis B cirrhosis get decompensated liver disease
20% over 5 years
Treatment of hepatitis B?
DAA
Or pegylated interferon
Depends on genotype
Baby born to mom who is Hep B eag positive
Immunoglobulin and vaccine rapid schedule decreases transmission to baby by 90%
acute viral hepatitis investigations
lft clotting hav igm hep b sag hcv ab and rna hev
inform PH
treatment Hep A
supportive self limiting flu like coryzal never chronic vaccine for close sex- 4 weeks before or house contacts vaccine works within 7 days otherwise. an offer ig if worried about fulminant- rare infectious 2 weeks after i’ll see most infectious before 1-2 weeks
treatment HEV
supportive
ribavarin
chronic hepatitis B treatment
depends on age ALT, dna
status of cirrhosis orfibrosis
or coinfection
treat any age or stage if vl more than 20000 and abnormal alt over 30
treat more aggressively if younger <30
vl >2000
treatment of decompensated liver disease
NRTI
entecavir
tenofovir
treatment hep b. compensated liver disease
pegylated interferon cytokines class interferes with viral replication
side effects
need contraception and men can’t conceive for -2 weeks
<40% success
48 weeks treatment
usually give entecavir or tenofovir instead
can add in lamivudine if not responding
Acute hepatitis how long is symptomatic prodrome?
Symptomatic Prodromal 1-3 weeks
Acute hepatitis how long is icteric phase?
Icteric Phase 2-24 weeks • Fever • Jaundice • Pale stools • Malaise • High ALT, high bilirubin
Signs of liver failure on bloods?
Liver failure:
• High ALT, high bilirubin • +INR>1.5
Incubation of hepatitis A?
4 weeks (15-45 days) incubation
Transmission of hepatitis A?
Common source outbreaks
Person to person
Contaminated food and water.
Outbreaks
Uncommon source
Exposure during travel to high endemicity areas
Who needs hepatitis A vaccine?
Foreign travelers
Contacts of hepatitis A
Occupational groups (travelling)
Patients with chronic liver disease MSM(during outbreaks)
Hepatitis B transmission?
Needles
Blood
Sex
Vertical
Who to vaccinate against hepatitis B?
Offer screening/vaccine to: • MSM • PWIDs • HIV-positive • HCV-positive • Partners of PWIDs and bisexual men • Partners/household contacts of patients with acute HBV/HBV carriers • Sexual assault victims and others according to risk • Sex workers
Offer screening only to:
All from HBV-endemic countries
Factors associated with reduced response rate to hepatitis b vaccine
Age >40 years
Sex – female have lower response Immunosuppression eg HIV, CRF Genetic factors – HLA types
How many with chronic hepatitis B get HCC?
5%-10% of chronic HBV- infected individuals
25% of those with cirrhosis
Isolated HepB cab
False-positive
‘Window period’ - before anti-HBs develops
Persistent failure to develop an anti-HBs response – occult HBV infection (can be genetic mutation- can’t detect surface ag. Do RNA/HCV ag. Can consider vaccine in interim)
Loss of detectable anti-HBs – late effect
Isolated HBsAg
Early acute infection
Anti-HBs and HBsAg
Dissociate immune complexes HBsAg variants
Which other tests do you need to evaluate chronic hepatitis B?
Liver profile • HBV DNA • Ultrasound liver /abdomen • Liver elastography (e.g. Fibroscan) • Hepatitis D Ab
Hepatitis D if acquired after hep B infection (super infection)- risks?
• flare of hepatitis • Fulminant hepatic failure (5%) • Increased risk of progression to cirrhosis and HCC • 80% chronic
How common is hepatitis D?
• Incomplete RNA virus • Only in presence of HBV infection • 5% of those with HBV • Worse outcomes Acquired with HBV, acutely • Acute hepatitis • only 2-5% become chronic
How to diagnose hepatitis D?
HDV antibodies
HDV RNA if antibody +
Hepatitis b incubation?
12 weeks (40-150 days) incubation
Hepatitis c incubation?
Incubation 8 weeks
Transmission of hepatitis c?
Injecting drugs,
contaminated blood products/needles, sex (HIV+MSM)
Most common reported risk factor in hepatitis C?
Most common reported risk factor is injecting drug use with sharing of drug taking equipment
• Prevalence 50% in PWID
Risk of vertical transmission hepatitis c?
Mother to infant:<5% - higher if mother also HIV positive (up to 40%)
risk of heterosexual transmission of hepatitis c?
HETEROSEXUAL TRANSMISSION
Total estimated risk of heterosexual transmission is low ?0.2- 2%/year
Which tests to do if hepatitis C Ab + with follow up testing showing HCV RNA+?
FBC U&E LFT auto ab HCV genotype USS fibroscan hep a ab refer to liver specialist
