Viral Hepatitis

Question 1

Hepatitis A - Transmission

Answer 1

Faecal-oral
Poor hygiene/overcrowding
Some imported cases
Clusters = gay men, injecting drug users

Question 2

Hepatitis A - Clinical

Answer 2

Acute hepatitis, no chronic infection
Peak incidence of symptomatic disease in children/younger adults
Usually ill for a few weeks then get better

Question 3

Hepatitis A - Lab Conformation fo Acute Infection

Answer 3

Clotted blood for serology

Hepatitis A IgM (usually detectable from onset of disease)

Question 4

Hepatitis A - Control

Answer 4

Hygiene

Vaccine prophylaxis

Question 5

Hepatitis E - Clinical

Answer 5

Acute hepatitis, no chronic infection
Peak incidence of symptomatic disease in children/younger adults
Usually ill for a few weeks then get better
Some immunocompromised humans can become chronically infected

Question 6

Hepatitis E - Incidence

Answer 6

More common in tropics

Has become more common than Hep A in UK

Question 7

Hepatitis E - Transmission

Answer 7

Faecal-oral

UK cases are thought to be through zoonoses (esp. pigs, deer and rabbits)

Question 8

Hepatitis E - Tropical Genotypes

Answer 8

In pregnant women, causes severe disease and likely death

Question 9

Hepatitis E - Control

Answer 9

No vaccine available yet

Question 10

Hepatitis D - Incidence

Answer 10

Can only infect those with Hep B

Exacerbates Hep B infection

Question 11

Hepatitis D - Co Infection

Answer 11

Have Hep B and Hep D at the same time

Question 12

Hepatitis D - Superinfection

Answer 12

Have Hep B, then go on to develop Hep D

Question 13

Hepatitis B - Transmission

Answer 13

Sex
Mother to child
Blood

Question 14

Hepatitis B - Higher Risk

Answer 14

People born in intermediate/high prevalence areas
Multiple sex partners
People who inject drugs
Children of infected mothers

Question 15

Hepatitis B - HBsAg

Answer 15

Hepatitis B Surface Antigen
Present in the blood of all infected individuals
Chronic infection = present for >6 months

Question 16

Hepatitis B - Clinical

Answer 16

Risk of chronic infection decreases with increasing age of exposure
Risk of acute hepatitis increases with age at exposure
Death is more likely to result from a chronic infection than an acute infection

Question 17

Hepatitis B - HBeAG

Answer 17

Hepatitis B e Antigen

Usually present in highly infectious individuals

Question 18

Hepatitis B - Hep B DNA

Answer 18

Always present in highly infectious individuals
Used to predict risk of chronic liver disease and monitor therapy
More sensitive than HBeAG

Question 19

Hepatitis B - Hep B IgM

Answer 19

Most likely to be present in recently infected cases

Question 20

Hepatitis B - Control

Answer 20

Safe blood
Safe sex
Needle exchange 
Prevention of needlesticks 
Screening of pregnant women
Pre-exposure vaccination 
Post-exposure prophylaxis (vaccine + HBIG)

Question 21

Hepatitis C - Transmission

Answer 21

Less easily transmitted by sex than Hep B
Mother to child
Blood

Question 22

Hepatitis C - Clinical

Answer 22

75% of cases result in chronic infection

Natural history not dependent on age at time of infection

Question 23

Hepatitis C - Lab Conformation

Answer 23

Test for antibody to Hep C 
\+ve = Past or active infection 
-ve = Not infected 
Test for Hep C RNA by PCR 
\+ve = Active infection 
-ve = Past infection

Question 24

Hepatitis C - Control

Answer 24

No vaccine

Must minimise exposure

Question 25

Hepatitis A - Natural History

Answer 25

Infection Mostly asymptomatic/acute hepatitis -> resolution Rarely (e.g. elderly) acute liver failure -> death or resolution

Question 26

Natural History of Chronic Infection - Hep B

Answer 26

Spontaneous cure not uncommon, eve after many years of infection

Question 27

Natural History of Chronic Infection - Hep C

Answer 27

Once chronic infection is established, spontaneous cure is not seen

Question 28

Hepatitis C - Natural History

Answer 28

Infection Mostly asymptomatic -> chronic infection -> chronic hepatitis -> cirrhosis -> chronic liver failure/cancer -> death 25% resolution from asymptomatic disease

Question 29

Hepatitis B - Natural History, Adult Infection

Answer 29

Infection Most asymptomatic/acute hepatitis -> resolution Less than 5% develop chronic infection/chronic hepatitis (some of these cases still resolve) Few result in cirrhosis -> chronic liver failure/cancer -> death

Question 30

Hepatitis B - Natural History, Infection at Birth

Answer 30

Similar to Hep C | high levels of chronic infection and complications

Question 31

Management of Acute Viral Hepatitis

Answer 31

``` Symptomatic No antivirals given Monitor for encephalopathy Monitor for resolution Notify Public Health Immunise contacts Test/vaccinate for other at risk infections ```

Question 32

Management of Chronic Viral Hepatitis

Answer 32

``` Antivirals Vaccination Infection control Decrease alcohol intake Hepatocellular carcinoma awareness/screening ```

Question 33

Antiviral Treatment - Who?

Answer 33

Chronic infection Risk of complications = inflammation present Fit for treatment = liver cancer contraindicates, cirrhosis and HIV make treatment more difficult Patient issues = side effects, lifestyle issues, attitude to treatment

Question 34

Antiviral Treatment - When?

Answer 34

Before complications Evidence of inflammation Patient is ready Clinical priority (e.g. HIV may be treated an controlled first)

Question 35

Antiviral Treatment - Interferon Alpha

Answer 35

Human protein Injected Genetically engineered

Question 36

Antiviral Treatment - Interferon Alpha - Side Effects

Answer 36

``` Common = Flu like Chills Sore muscles Malaise ``` Rarer but severe = Thyroid disease Autoimmune disease Psychiatric disease

Question 37

Therapy for Chronic Hepatitis B

Answer 37

Option 1 Interferon only Sustained cure possible, but only minority gain benefit and serious side effects Option 2 Suppressive antiviral drug Safer, but only suppression so no cure and possible resistance

Question 38

Aims of Chronic Hepatitis B Therapy

Answer 38

``` Reduce HBV DNA, lose HBeAg, lose HBsAg Improve liver biochemistry Improve histopathology Reduce infectivity Reduce progression Reduce mortality ```

Question 39

Aims of Chronic Hepatitis C Therapy

Answer 39

``` Response defied by loss of HCV RNA in blood sustained 6 moths after therapy (aka SVR) Improve liver biochemistry Improve histopathology Reduce infectivity Reduce progression Reduce mortality ```

Question 40

Principles of Hepatitis C Therapy

Answer 40

``` Choice of antiviral based on = Genotype of virus, viral load Genotype of patient's interferon response genes Stage of disease Past treatment experience Likelihood of side effects Cost effectiveness ```

Question 41

Hepatitis C Therapy - Newer Antivirals

Answer 41

Simeprevir, Ledipasvir, Daclatasvir = Used in certain genotypes in combo with other drugs Safe and well tolerated Sofosbuvir = Active against all genotypes in combo with other drugs Safe and well tolerated