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DipGUM > Hepatitis > Flashcards

Hepatitis Flashcards

1
Q

Hepatitis A - type of virus?

A

Picorna (RNA) virus

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2
Q

What is a picornavirus?

A

group of related nonenveloped RNA viruses

small, positive-sense, single-stranded

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3
Q

Where is hepatitis A infection most common?

A

Sanitation is poor (developing countries)

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4
Q

What is the route of transmission for hepatitis A?

A

Faeco-oral (food, water, close-contact)

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5
Q

What factors related to sex appears to increase risk of hepatitis A in MSM?

A 
oro-anal sex
Digital-rectal sex
Multiple sexual partners
Anonymous partners
Sex in public places
Group sex
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6
Q

What difference may occur in HIV positive people with hep A infection?

A

More infectious

not at increased risk

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7
Q

What situations have hep A outbreaks been reported in?

A

MSM
PWID
institutions for people with learning difficulties
contaminated batches factor VIII

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8
Q

How is a person infectious for with hep A?

A

2 weeks before and 1 week after JAUNDICE

HIV +ve >90 days

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9
Q

Describe the hep A outback in UK and Europe 2016-17?

A

3 strains/clusters
Spanish strain
Europride (Amsterdam) strain
Berlin strain

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10
Q

What number of hep A cases in England were linked to this outbreak?

A

266

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11
Q

What proportion of the UK outbreak with hep A were in MSM?

A

74%

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12
Q

Hepatitis A - incubation period?

A

15-45 days

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13
Q

What are the symptoms of hep A?

A

Most children and half adults ASYMPTOMATIC
Prodromal (3-10 days) - Flu-like illness + Right upper abdominal pain
Icteric (1-3 weeks) - jaundice + anorexia, nausea and fatigue

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14
Q

What is the typical hepatic dysfunction picture?

A

Mixed hepatic and cholestatic jaundice

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15
Q

What proportion of hepatitis A infection develops acute liver failure?

A

0.4%

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16
Q

What is overall mortality with hep A?

A

<0.1%

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17
Q

What is the mortality associated with hep A infection AND acute liver failure?

A

40%

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18
Q

What impact does hepatitis A have on pregnancy?

A

Increased miscarriage
Premature labour
Possible vertical transmission

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19
Q

Hepatitis A infection - diagnosis?

A

HAV-IgM positive

HAV IgG does not distinguish between current or past infection

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20
Q

How long does HAV IgM remain positive?

A

45-60 days although can be >6 months

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21
Q

Describe the LFT derangement in hep A?

A

Transaminases (AST/ALT) 500 - 10000

Bilirubin 500

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22
Q

What other blood test suggests severe hep A infection?

A

PT prolongation >5 secs

Acute liver failure typically PT > 50

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23
Q

What general advice should be given to people with acute hepatitis A infection?

A

Avoid food handling and unprotected sex until non-infectious

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24
Q

If a person is hep A positive what else should be screened for?

A

hepatits B, C and E

HIV and other STIs

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25
Q

How should acute icteric hepatitis be managed in hep A infection?

A

Mild/moderate - outpatient, rest, oral hydration

Severe - vomiting, diarrhoea, altered conscious level - admit to hospital

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26
Q

What contact tracing needs to take place following hepatitis A infection?

A

Recent partners 2 weeks before and 1 week after jaundice onset
Household contacts
At risk of food/water contamination
Notifiable disease

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27
Q

When can hepatitis A vaccine be given post exposure?

A

Within 14 days of contact with source if source was within infectious period

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28
Q

When should human normal immunoglobulin (HNIG) be considered?

A

If higher risk of complications

  • co-infection HBV/HCV or HIV
  • chronic liver disease
  • > 50 yrs
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29
Q

When should HNIG be administered post exposure to hepatitis A?

A

best within first few days of first contact

< 2weeks

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30
Q

HNIG may reduce disease severity even if administered after 2 week period. How long may it be useful for?

A

up to 28 days

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31
Q

How effective is HNIG and reducing risk of acquiring hepatitis A after contact?

A

90% effective if given within first few days

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32
Q

How should hepatitis A vaccine typically be dosed? What is the BASHH guidance?

A

0 and 6 months; all MSM SINGLE dose

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33
Q

What protection does hep A vaccine offer?

A

95% up to 10 years

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34
Q

Does hep A vaccine need repeated at 10 yrs?

A

increasing evidence that vaccine- induced immunity may be >20 years and possibly lifelong
if immunocompetent no boost/repeat course

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35
Q

What follow up should a person with acute hepatitis A have?

A

2 weekly LFTs until normal

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36
Q

Why does the BASHH guidance on hep A vaccination differ from the typical schedule?

A

International shortage of vaccine; however once sully restored offer full vaccination

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37
Q

Is it reasonable to screen for past hep A exposure/immunity prior to vaccination?

A

Yes

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38
Q

When might you opt to give vaccination prior to waiting for hep A antibody test result?

A

During outbreak situation

MSM will not return

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39
Q

What alternative vaccines can be used for hep A if monovalent or combined A+B are not available?

A

For emergency situation:
paediatric monovalent
hepatitis A/typhoid

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40
Q

Who else other that MSM should be vaccinated against hep A?

A

PWID with HBV or HCV infection

Travellers to developing countries

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41
Q

Hepatitis B - type of virus?

A

hepadna (DNA) virus

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42
Q

What is a hepadnavirus?

A

group of DNA viruses that infect hepatocyte

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43
Q

Hepatitis B virus in UK - seroprevalence?

A

0.01-0.04%

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44
Q

What is the zero-prevalence of HBV in PWID and MSM in UK?

A

> 1%

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45
Q

How many distinct genotypes are there for HBV?

A

8

genotype A-H

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46
Q

What sexual behaviours are associated with HBV infection and MSM?

A

multiple partners
unprotected anal sex
oro-anal sex

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47
Q

How likely is HBV sexual transmission between heterosexual regular partners?

A

18% infection rate; higher for sex workers

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48
Q

Other than sexual how is HBV acquired?

A

Vertical

Parenteral (PWID, blood products, occupational needlestick, non-sterile acupuncture/tattoos)

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49
Q

Hepatitis B - incubation period?

A

40-160days

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50
Q

In HBV the prodromal and icteric phases are very similar to hepatitis A, but may be more severe and prolonged. How common is acute liver failure?

A

<1%; but carries a worse outcome than HAV

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51
Q

How many phases of chronic HBV infection or carriage?

A

5 phases

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52
Q

Describe phase 1 of chronic HBV infection.

A

HB eAg +ve
HIGH levels DNA
NORMAL AST/ALT
little/no liver inflammation on biopsy

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53
Q

Describe phase TWO of chronic HBV infection.

A

HB eAg +ve
FALLING levels DNA
RAISED AST/ALT
liver inflammation on biopsy AND progressive FIBROSIS

54
Q

Describe phase THREE of chronic HBV infection.

A

HB eAg -ve
LOW levels DNA
normal AST/ALT

55
Q

Describe phase FOUR of chronic HBV infection.

A

HB eAg -ve
FLUCTUATING levels DNA - possible mutations
normal AST/ALT
INFLAMMATION and progressive FIBROSIS on biopsy

56
Q

Describe phase FIVE of chronic HBV infection.

A 
HB surfaceAg NEGATIVE
HB coreAb POSITIVE
possible HB sAb +ve
undetectable DNA
normal ALT
57
Q

In which phases of HBV chronic infection does progression to cirrhosis occur?

A

2 and 4

58
Q

What causes reactivation of hepatitis B infection?

A

Immunosuppression including Advanced HIV
Treatment of HBV and stopping treatment
chronic renal failure

59
Q

Co-infection with which infections leads to increased risk of HBV complications?

A

hepatitis C
HIV
delta virus infection

60
Q

What proportion of chronic HBV carriers will develop cirrhosis?

A

10-50%

61
Q

What proportion of HBV associated cirrhosis will lead to premature death?

A

50%

62
Q

What proportion of HBV associated cirrhosis will lead to liver cancer?

A

10%

63
Q

If hepatitis B surface antigen positive what advice should be given to patient?

A

No unprotected sex including oral-anal and oral-genital
Regular partners and close household contacts should be vaccinated
No organ/semen/blood donation until surface antigen negative

64
Q

When should a patient with HBV be referred to specialist in viral hepatitis?

A

surface antigen positive

65
Q

What considerations are made before hepatitis B treatment?

A

HBV DNA level

Liver inflammation/fibrosis

66
Q

When is treatment for chronic HBV typically offered?

A

HBV DNA >2000

evidence of liver necro-inflammation +/I fibrosis

67
Q

What treatment options are available for HBV alone?

A

tenofovir disoproxil and alfenamide (TDF or TAF)
Entecavir
Pegylated interferon

68
Q

Which ARVs can be used for both HBV and HIV infection?

A

Lamivudine or emtricitabine with TDF or TAF

69
Q

Why must a dual NRTI regimen be used when treating both HBV and HIV?

A

significant risk of ART HIV resistance if used as monotherapy

70
Q

Why should entecavir NOT be used for HBV treatment in HIV positive patients?

A

If HIV VL not suppressed entecavir can lead to M184V (3TC/FTC) resistant mutation

71
Q

What is the benefit of treatment or HBV?

A

reduced liver damage and decreased risk of liver cancer

72
Q

How frequently should a person with significant fibrosis/cirrhosis have follow up? What is the follow up?

A

6-12 monthly
Hepatology review
liver US and alpha-feta protein (AFP)

73
Q

Which patient groups are at highest risk of HCC developing without cirrhosis in HBV infection?

A

African >20 yrs old
Asian males >40 yrs old
Asian females>50 yrs old
Family history of HCC

74
Q

How common is vertical transmission with HBV infection?

A

HB eAg +ve 90% risk of transmission

HB sAg +ve, eAg -ve 10%

75
Q

Children infected with HBV through vertical transmission, what proportion are chronic carriers?

A

90%

76
Q

How can vertical transmission of HBV be reduced? How effective is it?

A

Tenofovir to mother third trimester
Hepatitis B specific immunoglobulin to baby
Vaccination at birth
Reduces vertical transmission 90%

77
Q

How soon after exposure to HBV infection should specific hepatitis B immunoglobulin (HBIG) be administered?

A

Works best within 12 hours
Ideally by 48 hours
No good after 7 days

78
Q

Who should be offered Hepatitis B vaccine in relation to a known source of infection?

A

All given HBIG
All regular sexual and household contacts
Give within 6 weeks
Ultra rapid or rapid accelerated course

79
Q

If a person has been vaccinated in the past and is then exposed to HBV infection, what should they be offered>

A

Single booster dose of hepatitis B vaccine

80
Q

What is the antibody response with ultra-rapid vaccination for HBV?

A

80% response within 4-12 weeks of third dose

Offer booster if no detectable antibody at 4-12 weeks

81
Q

What proportion will have an antibody response by 12 months following primary course of hepatitis B vaccination?

A

95%

82
Q

What proportion of HBV infection develop natural immunity lifelong after recovery from infection (sAg -ve)?

A

90%

83
Q

HB cAb +ve, sAg -ve with HB sAb and HB eAb negative, what might this suggest?

A

HB cAb false positive

84
Q

How can the possibility of HB cAb false positive be established?

A

Single hepatitis B vaccine dose will induce HBsAb +ve 4 weeks after vaccine if previous natural exposure to HBV

85
Q

What test should be used for hepatitis B screening?

A

HB cAb
or
HB sAg

86
Q

Who should be offered hepatic B vaccination as primary prevention?

A 
MSM
Sex workers
PWID
HIV +ve
Sexual assault victims
People from high prevalence HBV - Western Europe, North America, Australasia
Needlestick
Heterosexual with >10 partners/year
Sexual partners of positive or high risk of HBV
87
Q

What impact does HIV have on response to hepatitis B vaccine?

A

Reduced response
Better if CD4 cell count >500 and VL undetectable
Become HBsAb NEGATIVE more quickly

88
Q

If double dose hepatitis B vaccine is used for PWLH, what effect does it have?

A

increases response by 13%

89
Q

Hepatitis D (delta virus) - describe what it is?

A

Small incomplete RNA virus

Only infects people with HB sAg +ve infection

90
Q

Who is at risk of hepatitis D?

A

acquired the infection abroad
PWID and their sexual partners
sex workers

91
Q

When should hepatitis D be suspected?

A

Acute hepatitis severe
or
further attack in HBV infection

92
Q

What is the clinical implication of co-infection with HBV and HDV?

A

High rate of fulminant hepatitis and cirrhosis

Rapidly progressive liver disease

93
Q

How is hepatitis D diagnosed?

A

Should be tested in all HBV positive

positive anti-HDV antibody

94
Q

What is hepatitis D response to antivirals?

A

Poor

95
Q

Hepatitis C - type of virus?

A

RNA virus in flaviviridae family

96
Q

What is a flaviviridae?

A

positive, single-stranded, enveloped RNA viruses

97
Q

How many people in UK are infected wit HCV?

A

215 000

98
Q

What are the most common genotypes of HCV?

A

1 and 3

99
Q

What proportion of HCV in UK are genotype 1 or 3?

A

90%

100
Q

What is the most common route of transmission of HCV in UK?

A

Parenteral spread

101
Q

What is the rate of sexual transmission of HCV in heterosexual couples?

A

<0.1% in 10 years

102
Q

What is the steadily increasing incidence of HCV in MSM linked to?

A

HIV co-infectionn

103
Q

What other factors increase the risk of sexually acquired CV?

A 
MSM
-Co-infection syphilis or LGV
-traumatic anal sex
-fisting
-sharing sex toys
-communal lubricant
-group sex
-sero-sorting
-recreational drug use
Sex workers
104
Q

What is the rate of vertical transmission of HCV?

A

5%

7% if HIV co-infection

105
Q

Hepatitis C - incubation period?

A

4 to 20 weeks

106
Q

What proportion of HCV infection is serology positive at 3 months?

A

90%

107
Q

What proportion of HCV infection is asymptomatic?

A

Majority >60%

108
Q

How likely is acute fulminant hepatitis in HCV infection?

A

Rare <1%

109
Q

What proportion of HCV infection become chronic carriers?

A

50-85%

110
Q

What makes spontaneous clearance of HCV more likely?

A

favourable polymorphisms around IL28B gene

111
Q

What proportion of significant liver disease from HCV can occur with normal transaminases?

A

35%

112
Q

30% chronic carriers HCV will progress to severe liver disease, after what period of time?

A

14-30 years

113
Q

How soon after initial infection will HCV-RNA be detectable?

A

2 weeks

114
Q

Define acute hepatitis C infection.

A

Recent exposure to HCV
HCV-RNA positive
likely HCV antibody negative

115
Q

What is a surrogate marker of HCV replication? What is its limitation?

A

HCV core antigen

Less sensitive than HCV RNA

116
Q

What general advice should be given to those will HCV infection?

A

Curable or spontaneously clear
Should not donate blood, semen or organs
Refer to specialist

117
Q

In addition to STI tests and LFTs what other investigation may be considered?

A

Fibroscan

Liver US

118
Q

What is the goal of HCV treatment?

A

CURE HCV infection

REDUCE liver fibrosis, cirrhosis, HCC and extrahepatic manifestations

119
Q

Define HCV cure.

A

Negative CV RNA in blood 12 weeks after completion treatment

120
Q

Define HCV spontaneous resolution

A

loss of HCV RNA in first 6 months

121
Q

When is treatment for HCV indicated?

A

acute HCV with <2 log10 decline in RNA by week 4
or
HCV RNA remains positive by week 12

122
Q

How long should HCV monitoring continue if treatment not indicated?

A

48 weeks

123
Q

What classes of direct-acting antiviral agents (DAAs) are used?

A

NS3/4 protease inhibitors
NS5A
NS5B

124
Q

What considerations are made when deciding on DAA of HCV infection?

A 
HCV genotype and viral load
liver disease stage
prior HCV treatment 
co-morbidity
Drug-drug interactions
125
Q

Can treatment be offered in pregnancy?

A

No

Small risk vertical transmission

126
Q

Who should contact tracing include for HCV infection?

A

Sexual partner if patient or partner HIV +ve

PWID sharing needles

127
Q

What follow up is required for chronic untreated HCV?

A

6-12 monthly fibroscans

128
Q

HCV + advanced fibrosis/cirrhosis require what follow up?

A

6 monthly HCC screening

  • liver US
  • AFP
129
Q

Does past HCV infection protect a person from further acute infection?

A

NO
Neither past cleared or treated or chronic infection
Dual/super infection well documented

130
Q

What group of patients may be at risk of HCV especially pre1990?

A

Haemophiliacs
or
people who received blood or blood products
If untested - TEST

131
Q

When did screening of blood products for HCV start in the UK?

A

September 1991

DipGUM (39 decks)

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