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Carolyn Tabora, M.D.

Self limiting infection that predominantly affects the liver resulting in necroinflammatory response CAUSES: virus, alcohol, drug-induced, autoimmune HISTORY: prodrome of non-specific symptoms ( fever, malaise, anorexia, fatigue, myalgia ) -> jaundice & RUQ pain P.E.: jaundice -> yellowish discoloration of the skin, icteric sclera, dark colored urine, light colored stool : RUQ tenderness, hepatomegaly

DIAGNOSIS:

1. History & P.E. 2. elevated liver enzymes ALT/SGPT & AST/SGOT 3. elevated bilirubin causing jaundice 4. Hepatitis serology identifies the presence of the organism 5. Imaging studies: UTZ TREATMENT: 1. supportive 2. monitor for resolution of SiSx over time 3. anti-viral agents for chronic infection 4. liver transplantation Rx of choice for endstage liver failure & fulminant hepatitis

HEPATITIS A - is a liver disease caused by the hepatitis A virus (HAV). Hepatitis A can affect anyone. It is transmitted via fecal-oral route and is self-limiting.

HEPATITIS B - is a serious disease caused by a virus that attacks the liver. The virus, which is called hepatitis B virus (HBV), can cause lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, and death.

HEPATITIS C - is a liver disease caused by the hepatitis C virus (HCV), which is found in the blood of persons who have the disease. HCV is spread by contact with the blood of an infected person. HEPATITIS D - is a liver disease caused by the hepatitis D virus (HDV), a defective virus that needs the hepatitis B virus to exist. Hepatitis D virus (HDV) is found in the blood of persons infected with the virus.

HEPATITIS

E - is a liver disease

caused by the hepatitis E virus (HEV) transmitted in much the same way as hepatitis A virus & with the same course as Hepatitis A

CLINICOPATHOLOGIC SYNDROME 1. Carrier State an individual harbors the organism & is capable of transmitting the organism; but, no elevation of liver enzyme and remains asymptomatic 2. Asymptomatic Infection an individual with the organism with minimal elevation of the liver enzymes; however, manifests with no signs & symptoms 3. Acute Hepatitis an individual has the organism, is capable of transmitting the organism, & is symptomatic

4. Chronic Hepatitis symptomatic individual; biochemical or serologic evidence of continuing or relapsing hepatic disease for > 6 months w/ histo evidence of inflammation & necrosis 5. Fulminant Hepatitis progression of hepatic insufficiency from onset of SiSx to hepatic encephalopathy w/in 2-3 weeks

HBV

is a 42-nm DNA virus classified in the Hepadnaviridae family Liver is the primary site for its replication Ave. incubation from exposure to onset of elevated liver enzymes: 60 days (range: 40-90 days) Ave. incubation from exposure to onset of jaundice: 90 days (range: 60-150 days)

Serologic

Markers of HBV Infection

1. 2. 3. 4. 5. 6.

HBsAg anti-HBs HBcAg antiHBcAg HBeAg antiHBeAg

HBsAg - ongoing HBV infection - only serologic marker detected during the first 3-5 weeks - ave. time from exposure to detection is 30 days (range 6-60 days) - highly sensitive single sample nucleic acid tests can detect HBV DNA in the serum of an infected person 10-20 days before the detection of HBsAg

antiHBsAg

- immunity from HBV infection - infection or immunization of one genotype of HBV confers immunity to all genotypes antiHBcAg - acute, recently acquired, or chronic infection - IgM or IgG class of antiHBc

HBeAg

- viral replication & high levels of virus -> high infectivity - more infectious sec. to more levels of HBV - loss of replicating virus & with lower levels of virus

antiHBe

A bloodborne & sexually transmitted diesease Acute or chronic Rates of new infections & acute disease are highest among adults Risk for chronic infections is inversely proportional to age at infection:
Infants 90% Children 30% Adults 2-6%

MODES

OF TRANSMISSION: Percutaneous puncture through the skin Mucosal direct contact with mucous membrane Exposure to infectious blood or body fluids Infants & children 2 primary sources of HBV infection: perinatal transmission & horizontal transmission Adolescents high risk sexual activity like multiple sexual partners & male sexual activity w/ other males Transmission of HBV via blood transfusion is rare because of donor screening for HBsAg

RISK FACTORS 1. Persons of Asian, Alaskan, SubSaharan African descent 2. History of IV drug use 3. History of STD 4. Multiple sexual partners 5. Worker or patient in a hemodialysis unit 6. Health care or public safety worker

RISK FACTORS 7. Household contact with Hepatitis B carrier 8. Sexual contact with Hepatitis B carrier 9. Worker or residence in an instiution for the developmentally disabled 10. History of blood transfusion 11. Delivery to a carrier mother

Transmission

of HBV from mother to infant is one of the most efficient modes of HBV spread Major Concern: risk for the infant of developing chronic liver disease & its sequale ( liver cirrhosis & hepatocellular CA) Prevention: Immunization

HEPATITIS B VACCINE HBsAg is the antigen used for Heb B vaccination Purified from plasma of persons w/ chronic HBV infection or produced by recombinant DNA technology Contains 10-40 ug HBsAg protein/ml Single antigen-formulation & also in fixed combination w/ other vaccines Single-antigen: Recombivax & Engerix-B Combination: Twinrix for adults, Pediarix & Comvax for infants & young children

HBIG Passively acquired antiHBs Temporary protection ( 3-6 months ) Prepared from the plasma of donors w/ high concentrations of antiHBs Adjunct to Hepatitis B vaccine for post exposure immunoprophylaxis Administered alone as the primary means of protection after an HBV exposure for non responders to Hep B vaccination

Group Infants born to HBsAg (+) mothers

Recombivax HB 0.5 ml

Energix-B 0.5 ml

Children < 10 yrs


Children / adolescents 10-19 yrs Adults > 19 yrs

0.5 ml
0.5 ml

0.5 ml
1.0 ml

1.0 ml

1.0 ml

CONTRAINDICATIONS TO VACCINATION Hx of hypersensitivity to yeast or to any vaccine component Hx of serious adverse events (anaphylaxis) after receipt of Hep B vaccine Moderate or severe acute illness, with or w/o fever

NO CONTRAINDICATIONS Hx of Multiple Sclerosis Hx of GBS Autoimmune diseases ( SLE, RA ) *Pregnancy & Breastfeeding are not a contraindication to vaccination

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