Hepatitis and STIs Flashcards
What type of virus is hepatitis A?
RNA Virus
What is the epidemiology of HAV?
Suspect in the returning traveller with Hepatitis features
1.5 million infections worldwide, most are probably sub-clinical
You can do population wide testing to determine the epidemiology of HAV in your country:
* Use IgG to determine population exposure
* Low <15%, intermediate 15-50%, high >50%
High population exposure = high levels of immunity
Explain who Low, Intermediate and high endemnicity are important concepts in HAV?
Areas with Low transmission: probably people are unlikley to present with the virus, so from a public health perspective you don’t need to worry too much about the virus
Areas with high transmmission: The general population have a baseline good immunity against HAV so are unlikely to get very sick from it
Intermediate: There is reasonably high risk of getting HAV + reasonably low risk of having immunity against it –> highest clinical burden of HAV disease
How is HAV spread?
Faecal - Oral route
**wash your fruit and veg
Who is more likely to present with HAV - children or adults?
Adults –> do have clinical symps of HAV, adults only need a low serovar, but children need a very high level of infection to show symptoms
> 90% of children under 5 are asymptomatic
What is the incubation of HAV?
7-14 days (hence, the returning traveller); it is an ACUTE virus remember!
How does HAV present?
Acute Hepatitis:
* Jaundice
* Anorexia, fever, fatigue, malaise, diarrhoea,
abdominal pain
* Spontaneous resolution without chronic sequelae
Extra-Hepatic features:
- myocarditis, GBS, AKI, Interstitial nephritis
What is the Liver Enzymes picture in HAV?
ALT >1000
Raised AST, raised GGT, raised Alk Phos
How do you diagnose HAV?
Anti-HAV IgM (acute infection)
Anti-HAV IgG (shows immunity; can be raised for decades after initial infection)
HAV RNA
What are the complications of HAV?
- Recurrence (3-20%)
- Fulminant Hepatitis (more common in Hep E)
- Death (2-5% in adults)
How do you prevent HAV?
WASH
Food Hygiene
Vaccination (2x dose vaccine in high-risk people; travellers, MSM, children in intermediate risk countries)
How do you manage HAV?
Supportive care only
some patients might be considered for liver transplant
What is the epidemiology of Hep B?
Western Pacific
Subsaharan Africa
Asia
What kind of virus is Hep B?
DNA
Does HBV cause acute or chronic infection?
Primarily chronic (but some people do present with acute hepatitis)
How is Hep B transmitted?
Blood Borne
Why is PMTCT important in the context of HBV?
90% of infants infected will go on to have chronic liver damage/chronic infection
Maternally acquired HBV associated with:
* Increased risk of progression to cirrhosis
* Lower rate of spontaneous HBsAg loss
* Higher rate of viral replication
What 3 things can you do to prevent HBV vertical transmission?
- Vaccine neonate within the first 24h of life
- Give tenofovir to mothers with High HBV DNA (>200000) or HBeAg
- Give HBV immunoglobulin to the neonate within 24h if maternal HBV DNA >200000 or HBeAg +ve
Re: HBeAg = indicator of actively replicating virus
Is there a vaccine for Hep B?
Yes - 3 doses
**Birth dose is crucial, but often missed, increasing the risk of maternal to child transmission
How do you diagnose HBV?
HBsAg - indicates active infection
±HBV DNA (helps to determine severity)
±HBeAg (indicates actively replicating)
–> can be RDT or ELISA
In regards to HBV, What does HBeAg tell you?
Presence of actively replicating virus
In regards to HBV, what does Anti HBc tell you?
Exposure to HBV (past or current)
In regards to HBV, what does Anti-HBs tell you?
Immunity to HBV
Who and how do you treat HBV?
WHO:
All people who are also HIV +ve
Pregnant women with high viral loads
In HIV negative people, people should be treated for
HBV based on:
* ALT
* HBV DNA
* HBeAg
* Age
* Family history of HCC
* Extent of liver fibrosis
HOW:
Tenofovir or entecavir
How does HIV promote increased fibrosis in HBV/HCV infection?
- HIV has tropism for hepatic stellate cells via CXCR4 and CCR5
- HIV triggers proinflammatory cascade in hepatic stellate cells
What is the Epidemiology of Hep C?
Western Pacific
Subsaharan Africa
Eastern Europe
What kind of virus is HCV?
RNA virus
Which chronic Hepatitis virus can be cured?
HCV
What is the most important risk factor for HCV infection?
IVDU
How do you diagnose HCV?
Anti-HCV Antibody (RDT, ELISA)
+
HCV RNA
Why confirm?? Because 50% of HCV +ve cases are false positives on RDT
Who should get HCV treatment?
A. Patients with cirrhosis
B. HCV RNA >100,000 IU/ml
C. Persistent ALT elevation
D. Everyone
D. Everyone (curable, not worth the risk of HCC/cirrhosis)
What is the most common drug used in HCV treatment?
Sofosbuvir
**many drugs available, but you should use a regime that is PAN-GENOTYPIC
What hepatitis viruses are spread through the faecal oral route?
A, E
Which Hepatitis Viruses are BBVs?
B, C, D
What is the most common form of Hepatitis globally?
Hepatitis B
What is the most common cause of ACUTE hepatitis globally?
Hepatitis E
What is Hepatitis D?
HDV is a small satellite RNA virus that can cause co- infection with HBV or super infection in HBsAg positive people
What viral co-infection is required for Hepatitis D (HDV) to cause infection?
HBV
How does Hepatitis D cause disease?
- Acute co-infection with HBV Virus:
- Acute Hepatitis –> Fulminant Hepatitis –> Hepatic necrosis –> Death - Super co-infection with HBV Virus:
- Chronic hepatitis –> accelerated fibrosis
- high risk of HCC
What are the main complications of Hepatitis B and hepatitis D?
Fulminant Liver Failure (acute)
Liver cirrhosis
HCC
Death
How do you diagnose HVD infection?
Anti HDV Antibodies (IgM or IgG) (ELISA)
+
HDV RNA for confirmation
What is the epidemiology of HDV?
5% of people with HBV have HDV
endemic in West and Central Africa,
Middle East, Eastern Europe and Mongolia
How is HDV transmitted?
Blood Borne Virus
What are the risk factors for HDV?
IVDUs
MSM
Commercial sex work
Haemodialysis
Hep B and C
HIV
How do you manage HDV?
- Only licensed treatment is interferon- disappointing results- SVR in 20-30%
How can you prevent HDV?
Vaccine against HBV
Prevent MTCT
Encourage safe sex
Screen blood for HBV
What type of Virus is Hep E?
RNA Virus
What is the epidemiology of Hep E?
Commonest cause of acute Hepatitis World wide
3 million symptomatic cases/year
70000 deaths
What are the 4 main genotypes of HEV?
HEV 1: Acute infection, Faecal oral route, occurs in humans. Linked to waterborne outbreaks
HEV 2: Acute infection, Faecal oral route, occurs in humans. Linked to waterborne outbreaks
HEV 3: Zoonotic and humans. Can cause chronic infection in immunocompromised people. Linked to infected meat consumption
HEV 4: Zoonotic and humans. Linked to infected meat consumption
Who is most at risk of severe Hepatitis E infection?
Pregnant women
- Significantly higher mortality in pregnant women
- Seen only with HEV 1 and 2
- Mortality 20-25%, usually in 3rd trimester
- Stillbirth common, 3000/year
Theory: maternal immune tolerance
What is the incubation of Hepatitis E?
2-6 weeks
How does Hep E present?
Hepatitis
Jaundice
Fever, nausea, abdominal pain, vomiting,
hepatomegaly
Neuro Sequelae (more common than in HAV) - occurs in 5% of cases
GBS
Meningoencephalitis
What does the ALT look like in HEV?
ALT >1000-4000
How do you diagnose HEV?
Anti HEV Antibodies (IgM/IgG)
+
HEV RNA
Is there a vaccine for HEV?
Yes - but only recommended in OUTBREAKS
What is the management of HEV?
Ribivirin
±
Interferon
(esp. in immunocompromised with HEV Type 3)
Which HEV is assocaited with immunosuppressed patients?
HEV 3
Which of these infectious diseases is
associated with the highest annual global
mortality?
A. HIV
B. Tuberculosis
C. Malaria
D. Viral hepatitis
E. Dengue
E: Viral Hepatitis
A. HIV 1.07 million
B. Tuberculosis 1.18 million
C. Malaria 619,000
D. Viral hepatitis: 1.45 million
E. Dengue 40,467
HBV and HCV: 96% of viral hepatitis mortality and 91% of viral hepatitis DALY
What is the only DNA Hepatitis virus?
HBV
What are the three primary causes of genital ulceration?
Syphilis
Genital Herpes
Chancroid
What is the management of Syphillis?
IM benzathine penicillin 2.4 million units
What Bacteria causes Chancroid
Haemophylus Ducrei
