Module 2: Chapter 6 Hepatitis Flashcards
Is Hep A virus SS or DS RNA or DNA?
SS RNA.
Hep A transmission,
fecal oral. o Contaminated foods (e.g. raw seafood) often consumed by travelers to endemic countries o Outbreaks can occur if infected food handlers don’t properly wash hands o Anilingus (mouth to anus contact)
Incubation time of HAV, and Liver tests displayed
incubates for 28 days and flu-like symptoms appear with or without jaundice. - elevated ALT and AST, could be accompanied with high bilirubin and jaundice (80% chance of jaundice if over 14).
Diagnosing HAV
- elevated ALT and AST, could be accompanied with high bilirubin and jaundice (80% chance of jaundice if over 14). - anti-HAV antibodies. Could indicate immunity from a past infection of vaccination (gig antibodies) - need to confirm an acute infection through IgM anto-HAV antibody.
treatment and prevention of HAV
- preventable with vaccination. o HAV vaccine (e.g. Havrix®) with two doses given at 0 and 6 months o Combined HAV / HBV vaccine (e.g. Twinrix®) with three doses given at 0, 1, and 6 months About 3 weeks after the first dose of the HAV vaccine, 99% will have immunity for one year and the booster dose should provide immunity for 20-25 years Who should get the vaccine? o Persons travelling to endemic areas o Men who have sex with men (MSM) o Persons Who Inject Drugs (PWID) o Persons with chronic liver disease o Persons receiving clotting factors (e.g. Hemophilia) Close personal contacts of infected persons can receive post-exposure prophylaxis with immunoglobulin (IG) and vaccination to prevent outbreaks There is no specific therapy for HAV infection other than supportive care, while following the liver function tests and watching for the development of hepatic encephalopathy (HE)
Is HBV DD or SS RNA or DNA
DS DNA
HBV is the leading cause of ___ ___
hepatocellular carcinoma (primary liver cancer) world-wide, which is the second leading cause of cancer related deaths globally
types of HBV transmission
- vertical, horizontal (between infected children), parenteral (infected blood exposure), sexual.
incubation period of HBV. Presentation/History of HBV in Adults and Children
After an incubation period of approximately 120 days (range 45-160 days) symptoms of a viral illness may appear (with or without jaundice) The age at exposure, and maturity of the immune system, determine if an individual will develop symptoms of jaundice and acute hepatitis (usually with clearance of the virus) or a sub- clinical illness that becomes a chronic infection o Babies infected at birth or before their first birthday rarely develop symptoms but frequently develop chronicity (90-95%) o Older children and adult patients may develop jaundice with acute hepatitis but most will recover with life-long immunity (chronicity develops in < 5%) Acute HBV in adults can cause an elevation of hepatocellular liver tests (ALT and AST) which can be severe (>1000) and this may be accompanied by jaundice and an elevated bilirubin. If the INR is elevated it may indicate pending acute liver failure (ALF), so you must watch for the development of encephalopathy.
Diagnosis of HBV
infection is made by testing antigens (parts of the virus) or the antibodies to these antigens, with active viral replication being confirmed by measuring HBV DNA by polymerase chain reaction (PCR).
Hepatitis B surface antigen (HBsAg) is a marker of infection, which could be acute or chronic Anti-HBs antibody (total) indicates the development of immunity, which could be from clearing the infection (natural immunity) or by receiving vaccination
Total anti-HBc (core) antibody will measure both IgM and IgG antibodies to the core antigen and a positive test indicates exposure to the virus (active or past infection)
- o Natural immunity from a past infection (IgG antibodies) patient will be HBSAg negative
- o Ongoing infection patient will also be HBSAg positive
- Acute infection (or recent reactivation) must be confirmed by having a positive IgM anti-Hbc Antibody.
Hepatitis Be antigen is from the pre-core region of the genome and is often associated with high levels of viral replication of the virus (wild type)
- Anti-HBe antibodies develop when a person clears the HBe antigen, indicating the virus is entering a lower level of viral replication
o However, some individuals with a mutation in the pre-core or core promotor region of the virus can have active viral replication (HBV DNA detected) but are HBeAg negative and anti- HBe antibody positive (pre-core mutants)
Draw out the phases of Hepatitis B in terms of what you’d see in serology, HBVDNA, ALT, biopsy findings, and treatment
regular surveillance to follow their liver tests and
HBV DNA, and should (depending on their age) have surveillance for hepatocellular
carcinoma (HCC) with ultrasound ± alpha-fetoprotein (AFP) every six months
Prevention and Treatment of HBV
HBV is preventable with vaccination and there are two forms of the vaccine
o HBV vaccine (e.g. Engerix-B® or Recombivax HB®)
o Combined HAV / HBV vaccine (Twinrix®)
o Three doses are given at 0, 1, and 6 months
Pre-exposure HBV vaccine is 95-100% effective in adults who complete the vaccine series and it is thought to provide protection for life
Post-exposure HBV vaccine, given with one dose of hepatitis B immunoglobulin (HBIG), is 85-95% effective in preventing vertical transmission in neonates born to HBsAg+ mothers
Pegylated interferon is given as an injection weekly for 6-12 months. Stimulates the immune system to fight the virus. Mut be avoided in pregnancy, and can cause cirrhotic patients to demonpensate.
Oral Agents like Nucleoside (Lamivudine, telbivudine, entecavir) or Nucleotide Analogues (tenofovir TAF, adefovir) to prevent viral replication.
Monitoring of ALT and HBVDNA, even if not on treatment (phase 1 and 4), and Hepatocellular Carincoma surveillance must occur via ultrasound every 6 months, if you fall into these groups :
o Cirrhotics (regardless of age)
o Africans >20 years old
o Asian males >40 years
o Asian females > 50 years
o Persons with a family history of HCC (start earlier)
Is Hep C SS, DS RNA or DNA
SS RNA.
More than 75% of infections in North
America occur in baby-boomer and most aren’t aware that they are infected
Transmission is primarily parenteral,
o Traditional medicine practices (e.g. cupping)
o Tattoos and piercings (especially if done in prison)
o Sexual transmission can occur if MSPs
Natural History of HCV: Incubation? Is it acute or chonric? What tests do you run
HCV has an incubation of approximately 45 days (range 14-180 days) but rarely causes
symptoms of acute hepatitis (sometimes seen in active injection drug users) and usually does
not cause acute liver failure
Spontaneous clearance of the virus occurs in only 15% of acute infections and 85% will become
chronically infected
Spontaneous clearance of the virus occurs in only 15% of acute infections and 85% will become
chronically infected . Patients usually do not have symptoms unless they develop cirrhosis. HCV is a common cause of cirrhosis and has been the leading indication for liver transplantation world-wide, and the most common cause of hepatocellular carcinoma (HCC) in North America. Cirrhosis may develop in approximately 20-30%
of individuals after 20-30 years of infection
How is Natural history of Hep C accelerated
by the regular consumption of alcohol, presence of NAFLD, older age at infection, co-infection with HBV or HIV
Cirrhotics have approximately a 5% chance per year of developing HCC and have a 50% chance
of developing decompensation over the next 10 years (ascites, variceal bleeding,
encephalopathy). Once decompensated, there is median survival of approximately 2 years and this is an indication
for liver transplantation (LT). Unfortunately, recurrence of the virus after LT is universal with 80% developing recurrent
hepatitis in the LT allograft. The natural history after LT can be accelerated by immunosuppression (anti-rejection drugs) and 20% may have cirrhosis within 5 years
Diagnosis of HCV
Diagnosis of HCV infection is made by testing positive for anti-HCV antibodies and must be
confirmed by detecting the HCV RNA by qualitative PCR
It is also important to note, that after spontaneous clearance of the virus or successful
treatment with anti-viral drugs (sustained virologic response), the anti-HCV antibody will remain positive for life and the test should not be repeated
YOU ONLY KNOW IF HCV is “CLEARED” IF ALT goes back to normal.
