Public health and viral hepatitis Flashcards

1
Q

What is the management of chronic HCV infection?

A

Rx dependent on genotype (1-6)
IFN treatments no longer recommended
Aim to have undetectable HCV titre of RNA at 6 months post-Rx
Current Rx: proteosomal inhibitors combo ± ribavirin

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2
Q

What are the side effects with ribavirin?

A

haemolytic anaemia,
cough.
Women should not become pregnant within 6 months of stopping ribavirin as it is teratogenic

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3
Q

What are the side effects of interferon-alpha based Rx?

A
flu-like symptoms, 
depression, 
fatigue, 
leukopenia, 
thrombocytopenia
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4
Q

How is chronic hepatitis C defined?

A

persistence of HCV RNA in blood for 6 months after exposure

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5
Q

What are the potential complications of chronic HCV infection?

A

rheumatological problems: arthralgia, arthritis

eye problems: Sjogren’s syndrome

cirrhosis (5-20% of those with chronic disease)

hepatocellular cancer

cryoglobulinaemia: typically type II (mixed monoclonal and polyclonal)

porphyria cutanea tarda (PCT): it is increasingly recognised that PCT may develop in patients with hepatitis C, especially if there are other factors such as alcohol abuse

membranoproliferative glomerulonephritis

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6
Q

What are the main stages in viral hepatitis Sx presentation/infection?

A

Stage 1: NO Sx
infected, viral replication

Stage 2: NON-SPECIFIC Sx

  • anorexia, nausea, vomiting, arthralgia, malaise, fatigue, itchy skin
  • difficult to Dx based on Sx

Stage 3: DARK URINE, PALE STOOLS

  • GI Sx and malaise
  • jaundice
  • may also develop RUQ pain and hepatomegaly

Stage 4: Sx RESOLVE

  • LFTs return to normal
  • jaundice disappears
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7
Q

How do some people not realise they have chronic hepatitis?

A
the initial (acute) infection may have been insidious and likely asymptomatic 
Would not be able to tell unless there were Sx
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8
Q

What is a clinical diagnosis of viral hepatitis based on?

A
  • history (jaundice and other associated Sx)
  • exposure (risk groups)
  • grossly elevated ALT/AST, moderately elevated GGT and ALP
  • vaccination history: (HAV and HBV absent)
  • Absence of other Sx indicating neoplasia or other causes
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9
Q

What is a laboratory Dx of viral hepatitis based on?

A

Serology: detection of Ab and/or Ag

  • usually by enzyme linked assays
  • detection of RNA or DNA by PCR
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10
Q

What are alternative older terms for HAV and HBV?

A

HAV: infectious jaundice

HBV: serum hepatitis (as spread via blood products)

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11
Q

What are the main points about HAV?

A

most infectious before Sx develop, but many are asymptomatic and mild. More severe in those with chronic liver disease.

Sx more common in adults than in children

Very rarely fatal

No chronic infection, individuals are immune following infection

No Rx, vaccine available

Faecal oral transmission

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12
Q

What is the relationship between Sx and Ig serotype for most viral infections?

A

by the time Sx appear, there will be detectable IgM titres

exception: measles

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13
Q

What are the methods to prevent HAV?

A

PRE-EXPOSURE
immunisation with purified inactivated whole virus vaccine

at risk groups in UK and travellers are encouraged to get vaccine

POST-EXPOSURE
public health will contact at risk individuals in outbreak
Vaccines and/or immunoglobulins are given

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14
Q

What are the main points about HBV?

A

spread by bodily fluids e.g. blood Vertical transmission is an important problem

many asymptomatic infections, but can cause fulminant infection leading to death

chronic infection leads to cirrhosis and HCC risk, but can be treated to keep viral load low

Vaccine available

Large number of people worldwide are infected with HBV

Highest susceptibility for chronic HBV with acute infection at birth (90%)

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15
Q

What are the different types of HepB Ag?

A

HBsAg: surface Ag, produced in mass so one of the first Ag that the immune system will generate Ab against

HBcAg: nucleocapsid core Ag, associated with having had an infection either chronic or resolved

HBeAg: only present in some strains of HBV, usually indicates acute or chronic active disease
HBeAg is a splice variant of HBcAg

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16
Q

What is the typical acute and chronic timelines for viral hepatitis?

A

acute < 6 months

chronic > 6 months (up to years)

17
Q

How is the degree of infectivity determined?

A

levels found by quantifying the amount of HBV virus

18
Q

What are the implications for a HIGH INFECTIVITY CARRIER?

A

much higher risk of developing serious complications from chronic infection e.g. HCC and cirrhosis
Also higher risk of being infectious (important for infected mothers for e.g. vertical transmission)

+ve: HBsAg, HBeAg, anti-HBs (total), HBV DNA

19
Q

What are the serology results for someone with successful HBV vaccination likely to show?

A

positive Anti-HBs (surface antigen, total)

negative on all other markers

20
Q

How is HBV infection prevented?

A

PRE EXPOSURE
Adults: given to at risk groups
Screening an immunisation of health care workers performing exposure prone procedures
All babies now offered HBV vaccine

POST EXPOSURE
vaccination and Ig can be administered
HCWs, babies of infected mothers, sexual exposure

21
Q

How is HBV screened for in expectant mothers?

A

screened at ante-natal clinic for HBV carriers
vertical transmission is interrupted for baby via administration of immunoglobulins (passive immunity) and vaccine at birth (active immunity)

22
Q

At what ages is the HBV vaccine available to babies?

A

8 weeks
12 weeks
16 weeks

Also in 6-in-1 vaccine

23
Q

What is the Rx of HBV?

A

treatable in some patients
PEGYLATED INTERFERON and/or antiviral agent
Some interferon free Rx also available
Antiviral agents include: entecavir and tenofovir
those more likely to be treated if co-infected with HIV

Rx dependent on stage and illness type

Referral to hepatologist

24
Q

What are the main points about HCV?

A

Spread by bodily fluids
many infections are asymptomatic
Chronic infection is common and may lead to cirrhosis and HCC

Chronic infection is treatable, but re-infection may occur

No vaccine available

HCV 10-100x less infectious than HBV

25
Q

When are you most likely to Dx HCV in the course of its infection?

A

more likely to make Dx in chronic stages
acute phases are often asymptomatic

RNA and abnormal LFTs are usually first marker to be detected in blood test

26
Q

What serology results would you expect in an infected HCV individual who has been successfully treated?

A

HCV RNA: NEGATIVE

IgG Ab: POSITIVE

27
Q

What serology results would you expect in an infected individual with chronic HCV?

A

HCV RNA: +ve

IgG Ab: +ve

28
Q

How is HCV infection prevented?

A

no vaccine

Prevention is largely based on avoiding exposure

29
Q

What is the Rx for HCV?

A

Curable in some individuals
response influenced by viral and host genotypes

Currently Rx: Antivirals and INTERFERON FREE Rx

30
Q

What is the old terminology for HCV?

A

NANB = non A non B hepatitis

31
Q

What are the main points about HDV?

A

transmitted by same routes as HBV

required HBV co-infection to mediate HDV infection

Rx: Target HBV to treat HDV

no vaccine, but HBV vaccine will prevent HBV and so HDV infections

32
Q

How is HDV Dx?

A

patient must have HBV infection

then detection of HDV RNA via PCR

33
Q

What are the main points about HEV?

A

Faecal oral transmission

may be acquired from pork

15-64 day incubation period

Generally mild, often asymptomatic

Can be more severe in pregnancy. Especially Asian genotypes that can cause fulminant disease.

Rx not usually needed

Vaccine available in China

34
Q

What lifestyle changes can be implemented to manage viral hepatitis?

A
  • prevent further damage to liver
  • avoid ingesting any hepatotoxic items e.g. EtOH
  • check medications with doctor to avoid further liver compromise
  • prevent further spread to others
  • Avoid IVDU
  • Do not share personal items
35
Q

Who is responsible for notification of hepatitis?

A

Clinician: duty upon presentation of Sx indicative of hepatitis

Lab: duty to notify once causative agents 9HAV, HBV, HCV, HDV, HEV) are identified