Viral Hepatitis

Question 1

hepatitis A - transmission

Answer 1

faecal-oral spread
poor hygiene/overcrowding
cases imported
gay men 
IV drug users
importance declined in UK

Question 2

hep a - clinical

Answer 2

acute hepatitis, no chronic infection

peak incidence of symptomatic disease in older children/young adults

Question 3

hep a - diagnosis

Answer 3

laboratory confirmation of acute infection
clotted blood for serology
hepatitis A IgM

control - hygiene, vaccine prophylaxis

Question 4

hepatitis E

Answer 4

more common in tropics
clinically like hep A
more common than hep A

faecal-oral transmission

evidence of chronic infection in pigs - common cause in UK

no vaccine available

some immunocompromised humans can get chronic infection

Question 5

hepatitis D

Answer 5

only found with hep B virus

parasite of a parasite

exacerbates hep B
co-infection or syperinfection

rare in scotland

Question 6

hepatitis B - transmission

Answer 6

sex
mother to child
blood

chronic infection more likely to result if first exposure is in childhood

Question 7

hep B - at risk groups

Answer 7

people born in areas of intermediate/high prevalence
multiple sexual partners
people who inject drugs
children of infected mothers

Question 8

hep B - diagnosis

Answer 8

laboratory confirmation
hep B surface antigen (HBsAg) present in blood of all infectious individuals
present for more than 6 months in chronic infection
highly infected = HBeAg

hep B IgM most likely to be present in recently infected cases
anti-HBs present in immunity

Question 9

hep B - control

Answer 9

minimise exposure - safe blood, safe sex, needle exchange, prevention of needle sticks, screening of pregnant women

two pre-exposure vaccination strategies in use in UK

post-exposure prophylaxis - vaccine, plus HBIG

Question 10

hepatitis C - transmission

Answer 10

similar to hep B
no vaccine available

infection results in chronic infection in about 75% of cases
natural history does not seem to be dependent on age at time of infection

Question 11

chronic infection

Answer 11

6 months of infection

time from infection to cirrhosis typically >20years

infection to hepatocellular carcinoma typically >30years

Question 12

chronic infection - Hep B

Answer 12

spontaneous cure not uncommon

even after many years of infection

Question 13

chronic infection - Hep C

Answer 13

once chronic infection established, spontaneous cure is not seen

Question 14

most common cause of viral acute hepatitis

Answer 14

hep E

Question 15

management of acute viral hepatitis

Answer 15

symptomatic
no antivirals given
monitor for encephalopathy
monitor for resolution
notify public health
immunisation of contacts
test for other infections if at risk
vaccinate against other infections if at risk

Question 16

management of chronic viral hepatitis

Answer 16

ANTIVIRALS

VACCINATION
other hepatitis viruses
if cirrhotic - influenza and pneumococcal

INFECTION CONTROL

ALCOHOL
drink as little as possible

HEPATOCELLUALR CARINOMA SCREENING
most important for patients with cirrhosis

Question 17

antiviral treatment of chronic viral hepatitis - who

Answer 17

CHRONIC INFECTION
HCV - RNA present and genotype known

RISK OF COMPLICATIONS
evidence of inflammation (mostly in Hep B)

FIT FOR TREATMENT
established cirrhosis more difficult to treat - priority
liver cancer = contraindication

patients may have other priorities

Question 18

antiviral treatment of chronic viral hepatitis - when

Answer 18

before complications

evidence of inflammation

when patient ready and clinical priority

Question 19

interferon alfa

Answer 19

not used in hep C
sometimes in hep B

Many side effects

given my injection as peginterferon
flu-like symptoms, chills, sore muscles, malaise
thyroid disease, autoimmune disease, psychiatric disease

Question 20

ribavirin

Answer 20

anaemia

Question 21

therapy for chronic hep B

Answer 21

SUPPRESSIVE ANTIVIRAL DRUG
safer, increasing range available
suppression not cure, resistance can develop

PEGINTERFERON
sustained cure possible
side effects, injections, only minority gain benefit

Question 22

benefits of chronic hep B therapy

Answer 22

virological
improved liver biochemistry
improved histopathology
reduced infectivity
reduced progression to cirrhosis and primary hepatocellular carcinoma
reduced mortality

Question 23

benefits of chronic hep C therapy

Answer 23

response defined by loss of HCV RNA in blood sustained to 6 months after end of therapy

sustained virological response 
improved liver biochemist 
improved histopahtology
reduced infectivity
reduced incidence of primary liver cancer
reduced mortality