Hepatitis B, C, D, E Flashcards
Hepatitis B transmission
- blood borne
- sexually transmitted
- can live on environmental surfaces for up to 7 days
Which body fluids have high viral concentration
- blood
- serum
- wound exudates
Which body fluids have moderate viral concentrations
- semen
- vaginal fluid
- saliva
Which body fluids have low/not detectable
- urine
- feces
- sweat
- tears
- breast milk
Worldwide at-risk population for hepatitis B
- endemic countries such as asia, sub-saharan africa
- children of HBV-positive mothers
- travelers to endemic areas
- sexual contacts
US at-risk population for hepatitis B
- sexual contacts
- household contacts
- IV drug users
- health care workers
- people working with /receiving blood products or dialysis
- residents/staff of facilities for developmentally disabled persons
There is an increased prevalence of Hepatitis B in what populations
- HIV + persons
- IV drug users
- men having sex with men
- sexual/household contacts of HBsAg + persons
Who should get tested for hepatitis B
- anyone with acute presentation of liver disease
2. anyone in risk groups
acute hepatitis B infection: incubation
30-180 days, mean 60-90
HPI/ROS of acute hepatitis B infection
- General: fatigue, low-grade fever
- Skin: erythematous rash, urticaria
- HEENT: jaundice at day 10
- GI: nausea, bloated feeling
- MS: arthralgias
- VS: fever
- Skin: rash, jaundice
- HEENT: posterior cervical lymph nodes, icteric sclera
- GI: tender, palpable liver edge {70%}
Surface antigen and antibody for hepatitis B
Antigen- HBsAg
Antibody- anti-HBs
Core antigen and antibody for hepatitis B
Antigen- HBcAg
Antibody - anti-HBc
e=nucleocapsid protein {similar to C}
Antigen: HBeAg
Antibody: anti-HBe
Polymerase chain reaction test for viral load of hepatitis B
- DNA amplification technique able to detect as few as copies/mL
- very expensive
Indications of viral load test
- treatment decisions
- response to treatment
- chronic infection
- unusual presentation
Prevalence of chronic HBV
- two billion people have incidence of infection
- 800,000 - 1.4 million infected in US
- ninth leading cause of death worldwide
What percent of children and adults with chronic hepatitis B infections will develop cirrhosis or liver cancer
25% of childhood
15% of adults
Antigens and antibodies for chronic Hepatitis B infection
- HBsAg positive for > 6 months;
- total anti-HBc positive;
- HBeAg may have significance in long-term clinical course;
Hepatitis D infection always requires what other infection and why
HBV infection because it uses HBV protein shell;
** can occur acutely as a co-infection with HBV or as a superinfection after HBV
What is the most common blood-borne infection in the US
Hepatitis C
How is hepatitis C spread
parenteral route
What percent of patients with hepatitis C develop chronic liver disease
40-60%
Risk groups for hepatitis C
- current/former injection drug user
- pre 1987 clotting factor recipients
- pre-1992 transfusion/organ recipient
- dialysis patient
- person with known HCV exposure
- person with HIV/HBV
- children born to HCV + mother
- persons born between age of 1945-1965
Clinical course for hepatitis C
- incubates over 6-7 months
- 25% of people develop jaundice
- 1% mortality rate in acute infection
symptoms of hepatitis C
typically asymptomatic, indolent, prolonged course until advanced liver disease develops
Who should get tested for hepatitis C
- ever injected illegal drugs
- infected with HIV/HBV
- unexplained abnormal ALT/liver disease
- born to HCV + mother
- ever on hemodialysis
- needlestick
- sexual partner to HCV + person
- received clotting factors made before 1987 or blood/organs before 1992
- born between 1945-1965
Lab testing for hepatitis C
- screens for HCV antibodies
- detects antibodies 28-90 days after exposure
- does not distinguish acute from chronic
- misses approximately 10% of positives
- may see ALT fluctuate wildly and does not predict the extent of liver damage
- follow positive screening result with confirmatory testing
hepatitis C viral load
PCR: HCV RNA+ one to two weeks after infection
Indication: acute infection suspected
anti-HCV ambiguous or unconfirmed, infection suspected with normal LFTs
- repeat if negative with high suspicion of infection
- no sure correlation between high titer and disease severity
Genotyping testing for HCV
- informs treatment decisions
- type 1 HCV most common in US
- type 2 and 3 most likely to respond to treatment {24 weeks};
- type 1 more resistant to treatment {48 weeks}
Cofactors for hepatitis C disease severity
- alcohol
- age over 40 at time of infection
- HIV coinfection
- male
- other coinfection
Out of every 100 people infected how many with hepatitis C will develop chronic infection
75-80
Out of every 100 people infected how many with hepatitis C will develop chronic liver disease
60-70
Out of every 100 people infected how many with hepatitis C will develop cirrhosis over 20-30 years
5-20
Out of every 100 people infected how many with hepatitis C will die from infection consequences
1-5
What are the extrahepatic manifestations of hepatitis C
- lymphoma
- diabetes
- glomerulonephritis
- porphyria cutanea tarda
- lichen planus
Chronic HBV treatment is based on
- ALT abnormality
- viral load
- positive/negative E antigen
- abnormal liver biopsy
Chronic HBV treatment is aimed at
viral replication;
- pegylated interferon and ribavirin
- protease inhibitors:
a. adefovir,
b. entecavir,
c. telbivudine,
d. tenofovir;
e. lamivudine {virus may become resistant
E antigen-negative treatment for Hepatitis B when normal ALT, viral lode under 10^5
- no treatment
2. follow with LFTs, alpha fetoprotein every 6 months
E antigen-negative treatment for Hepatitis B when abnormal ALT, viral load > 10^5
GI referral for treatment consideration
Chronic HCV treatment
- Ribavirin
- pegylated interferon
- telaprevir
- boceprevir
- simeprevir
- sofosbuvir
What is the duration for chronic HCV treatment
6-12 months
Duration for chronic HCV treatment depends on
- genotype
- viral load
- liver biopsy results
Side effects of chronic HCV treatments
- nausea
- fatigue
- irritability
- hair loss
- anemia
- neutropenia
interactions of chronic HCV treatments
multiple drug-to-drug interactions because of cytochrome P450
hepatocellular carcinoma is associated with
HBV and HCV
testing with hepatocellular carcinoma
alpha fetoprotein, liver US every 6 months
Liver transplant and HBV re-infection treatments
- HBIG: improved outcomes but expensive
- Famciclovir: less promising
- Lamivudine: greater resistance
- Combination therapy: HBIG, vaccine
Liver transplant and HCV reinfection treatments
- recurrent infection almost universal
- graft damage related to degree of immune suppression
- viral activity continues with immunosuppressants
Education/Prevention plan for Hepatitis
- safe sex
- clean needles
- universal precautions
- health promotion in those infected
- avoid alcohol/unnecessary medications/infection
Screening for hepatitis C should be done
- high risk groups
2. baby boomers 1945-1965
Vaccinations for HAV/HBV should be done for
- risk groups: STD clinics, HIV counseling/testing sites;
- correctional facilities;
- drug treatment clinics
- sexual and household contacts
- healthcare workers/first responders
- diabetics
HAV vaccine candidates
- all children 12-23 months
- unvaccinated adolescents, young adults
- IV drug users
- men who have sex with men
- travelers
- persons with any other chronic hepatitis
- clotting factor recipients
- persons who work with primates
Hepatitis A vaccines
different formulas for:
1. pediatric {12 months-18 years}
2. adult > 18 years
100% immunogenic
Common side effects for hepatitis A vaccine
- soreness at injection site
2. headache
Where is the hepatitis A vaccine given
deltoid injections for adults/adolescents;
for child: vastus lateralus
Hepatitis A vaccine and other vaccines
safe to give with other immunizations but use separate site
Hepatitis A vaccine dosing for travelers
- four weeks before travel give 1 dose
- less than 4 weeks before travel: dose one plus 0.02mg/kg immune globulin (Ig) IM at different site;
- give second dose 6-12 months after dose one for long-term protection
Do you test first before giving hepatitis A vaccine for traveling
yes if adult is > 40 born in or with history of travel to HAV-endemic areas
Postexposure prophylaxis for hepatitis A is given when
within 2 weeks of exposure
To whom do you give Postexposure prophylaxis for hepatitis A
if 40 +,health problems: immune globulin for passive protection;
What hepatitis A vaccine do you give to high risk groups
both vaccine and immune globulin
Candidates for HBV vaccine
- infants at birth
- catch up all others < 19
- multiple sex partners, MSM, STDs, HIV, HCV, chronic HBV+ sexual partners;
- healthcare workers
- IV drug users
- dialysis patients
- diabetes age 19-59 {higher incidence/poorer outcomes}
- travelers
Do you test first for HBV vaccine
- consider prevalence in pt population {high risk sex, IVDU, immigrant};
- consider cost of testing {HBsAg} including visit and vaccine
When do you do HBV testing after HBV vaccine
- ongoing risk of exposure
- healthcare worker
- high risk sex
- IVDU
- infected household
- obese
- in 4-8 weeks after 3rd vaccine dose
- anti-HBs
- full series vaccine for nonresponders
- copy of antibody titer lab results to patients
When do you not do HBV testing after HBV vaccine
infant, child, adolescent
HBV booster doses are recommended
only for hemodialysis patients
- test annually for anti-HBs
- administer booster if level < 10
HBV booster for immunocompromised patients
undetermined need but consider annual anti-HBs testing and booster if level < 10
HBV booster is not recommended for
vaccinated persons with normal immunity, low exposure risk
Post-exposure prophylaxis for known HBsAG + source
- as soon as possible, ideally within 24 hours
Post-exposure prophylaxis for known HBsAG + source booster dose
persons with written documentation of complete HBV vaccine series but no postvaccination testing
Post-exposure prophylaxis for known HBsAG + sourceHBIG and finish vaccine series on normal schedule
persons in vaccination process
Post-exposure prophylaxis for known HBsAG + source vaccine and HBIG
unvaccinated persons
- simultaneous administration, separate injection site
- vaccine series according to age-appropriate dose/schedule
Post-exposure prophylaxis for unknown HBsAG: no treatment
persons with written documentation of completed HBV vaccination series
Post-exposure prophylaxis for unknown HBsAG: vaccine series continued to completion
persons not fully vaccinated
Post-exposure prophylaxis for unknown HBsAG: vaccine series started as soon as possible
unvaccinated persons