* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Epidemiology and Prevention of Viral Hepatitis A to E:
Globalization and disease wikipedia , lookup
Vaccination wikipedia , lookup
Sociality and disease transmission wikipedia , lookup
Urinary tract infection wikipedia , lookup
Hygiene hypothesis wikipedia , lookup
Common cold wikipedia , lookup
Sarcocystis wikipedia , lookup
Transmission (medicine) wikipedia , lookup
Henipavirus wikipedia , lookup
Schistosomiasis wikipedia , lookup
West Nile fever wikipedia , lookup
Marburg virus disease wikipedia , lookup
Hospital-acquired infection wikipedia , lookup
Human cytomegalovirus wikipedia , lookup
Neonatal infection wikipedia , lookup
Childhood immunizations in the United States wikipedia , lookup
Infection control wikipedia , lookup
Epidemiology and Prevention of Viral Hepatitis A to E: An Overview Hepatitis Branch Centers for Disease Control and Prevention Viral Hepatitis - Historical Perspective “Infectious” Viral hepatitis “Serum” A E Enterically transmitted C Parenterally transmitted NANB B D F, G, ? other Viral Hepatitis - Overview Type of Hepatitis A Source of virus Route of transmission Chronic infection Prevention B C D E feces blood/ blood/ blood/ blood-derived blood-derived blood-derived body fluids body fluids body fluids feces fecal-oral percutaneous percutaneous percutaneous permucosal permucosal permucosal fecal-oral no yes pre/postexposure immunization pre/postexposure immunization yes yes blood donor pre/postscreening; exposure risk behavior immunization; modification risk behavior modification no ensure safe drinking water Acute Viral Hepatitis by Type, United States, 1982-1993 34% 47% 16% 3% Source: CDC Sentinel Counties Study on Viral Hepatitis Hepatitis A Hepatitis B Hepatitis C Hepatitis Non-ABC Estimates of Acute and Chronic Disease Burden for Viral Hepatitis, United States Acute infections (x 1000)/year* Fulminant deaths/year Chronic infections Chronic liver disease deaths/year HAV HBV HCV HDV 125-200 140-320 35-180 6-13 100 150 ? 35 0 1-1.25 million 3.5 million 70,000 5,000 8-10,000 1,000 0 * Range based on estimated annual incidence, 1984-1994. Hepatitis A Virus Hepatitis A - Clinical Features • Incubation period: • Jaundice by age group: • Complications: • Chronic sequelae: Average 30 days Range 15-50 days <6 yrs, <10% 6-14 yrs, 40%-50% >14 yrs, 70%-80% Fulminant hepatitis Cholestatic hepatitis Relapsing hepatitis None Age-specific Mortality Due to Hepatitis A Age group (years) <5 5-14 15-29 30-49 >49 Total Case-Fatality (per 1000) 3.0 1.6 1.6 3.8 17.5 4.1 Source: Viral Hepatitis Surveillance Program, 1983-1989 Hepatitis A Virus Infection Typical Serologic Course Symptoms Total anti-HAV Titer ALT Fecal HAV 0 1 IgM anti-HAV 2 3 4 5 6 Months after Exposure 12 24 Concentration of Hepatitis A Virus in Various Body Fluids Body Fluid Feces Serum Saliva Urine 100 102 104 106 Infectious Doses per ml Source: Viral Hepatitis and Liver Disease 1984;9-22 J Infect Dis 1989;160:887-890 108 1010 Hepatitis A Virus Transmission • Close personal contact (e.g., household contact, sex contact, child day care centers) • Contaminated food, water (e.g., infected food handlers, raw shellfish) • Blood exposure (rare) (e.g., injecting drug use, transfusion) Sources of Hepatitis A Virus Infection by Mutually Exclusive Groups, United States, 1983-93 Percentage of Cases 40 30 Personal contact 20 Day care center 10 Foreign travel Drug use Outbreak 0 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 Year Source: CDC, Viral Hepatitis Surveillance Program Geographic Distribution of HAV Infection Anti-HAV Prevalence High Intermediate Low Very Low Hepatitis B Virus Hepatitis B - Clinical Features • Incubation period: Average 60-90 days Range 45-180 days • Clinical illness (jaundice): <5 yrs, <10% ³5 yrs, 30%-50% • Acute case-fatality rate: • Chronic infection: 0.5%-1% <5 yrs, 30%-90% ³5 yrs, 2%-10% • Premature mortality from chronic liver disease: 15%-25% Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course Symptoms anti-HBe HBeAg Total anti-HBc Titer 0 4 anti-HBs IgM anti-HBc HBsAg 8 12 16 20 24 28 32 36 Weeks after Exposure 52 100 Progression to Chronic Hepatitis B Virus Infection Typical Serologic Course Acute (6 months) Chronic (Years) HBeAg anti-HBe HBsAg Total anti-HBc Titer IgM anti-HBc 0 4 8 12 16 20 24 28 32 36 Weeks after Exposure 52 Years Rate (per 100,000) Rate of Reported Hepatitis B by Age Group 25 United States, 1990 20 15 10 5 0 0-14 15-19 20-29 Age Group (Years) Source: CDC Viral Hepatitis Surveillance Program 30-39 40+ Chronic Infection (%) 100 Outcome of Hepatitis B Virus Infection by Age at Infection 100 80 80 60 60 Chronic Infection 40 40 20 20 Symptomatic Infection 0 Birth 1-6 months 7-12 months Age at Infection 1-4 years 0 Older Children and Adults Global Patterns of Chronic HBV Infection • High (8%): 45% of global population – lifetime risk of infection >60% – early childhood infections common • Intermediate (2%-7%): 43% of global population – lifetime risk of infection 20%-60% – infections occur in all age groups • Low (<2%): 12% of global population – lifetime risk of infection <20% – most infections occur in adult risk groups Geographic Distribution of Chronic HBV Infection HBsAg Prevalence ³8% - High 2-7% - Intermediate <2% - Low Concentration of Hepatitis B Virus in Various Body Fluids High Moderate blood serum wound exudates semen vaginal fluid saliva Low/Not Detectable urine feces sweat tears breastmilk Hepatitis B Virus Modes of Transmission • Sexual • Parenteral • Perinatal Elimination of Hepatitis B Virus Transmission United States Strategy • • • • Prevent perinatal HBV transmission Routine vaccination of all infants Vaccination of children in high-risk groups Vaccination of adolescents – all unvaccinated children at 11-12 years of age – “high-risk” adolescents at all ages • Vaccination of adults in high-risk groups Hepatitis D (Delta) Virus d antigen HBsAg RNA Hepatitis D - Clinical Features • Coinfection –severe acute disease –low risk of chronic infection • Superinfection –usually develop chronic HDV infection –high risk of severe chronic liver disease Hepatitis D Virus Modes of Transmission • Percutanous exposures –injecting drug use • Permucosal exposures –sex contact HBV - HDV Coinfection Typical Serologic Course Symptoms ALT Elevated Titer anti-HBs IgM anti-HDV HDV RNA HBsAg Total anti-HDV Time after Exposure HBV - HDV Superinfection Typical Serologic Course Jaundice Symptoms Total anti-HDV Titer ALT HDV RNA HBsAg IgM anti-HDV Time after Exposure Geographic Distribution of HDV Infection Taiwan Pacific Islands HDV Prevalence High Intermediate Low Very Low No Data Hepatitis D - Prevention • HBV-HDV Coinfection Pre or postexposure prophylaxis to prevent HBV infection • HBV-HDV Superinfection Education to reduce risk behaviors among persons with chronic HBV infection Hepatitis C: Leading-Edge Scientific and Clinical Advances Features of Hepatitis C Virus Infection Incubation period Acute illness (jaundice) Case fatality rate Chronic infection Chronic hepatitis Cirrhosis Mortality from CLD Average 6-7 weeks Range 2-26 weeks Mild (<20%) Low 75%-85% 70% (most asx) 10%-20% 1%-5% • Chronic Hepatitis C Factors Promoting Progression or Severity Increased alcohol intake • Age > 40 years at time of infection • HIV co-infection • ?Other – Male gender – Other co-infections (e.g., HBV) Serologic Pattern of Acute HCV Infection with Recovery anti-HCV Symptoms +/- Titer HCV RNA ALT Normal 0 1 2 3 4 Months 5 6 1 Time after Exposure 2 3 Years 4 Serologic Pattern of Acute HCV Infection with Progression to Chronic Infection anti-HCV Symptoms +/- Titer HCV RNA ALT Normal 0 1 2 3 4 Months 5 6 1 Time after Exposure 2 3 Years 4 Decline in injection drug users Decline in transfusion recipients / New Infections , Estimated Incidence of Acute HCV Infection United States, 1960-1999 Year Source: Hepatology 2000;31:777-82; Hepatology 1997;26:62S-65S Transmission of HCV • Percutaneous – – – – Injecting drug use Clotting factors before viral inactivation Transfusion, transplant from infected donor Therapeutic (contaminated equipment, unsafe injection practices) – Occupational (needlestick) • Permucosal – Perinatal – Sexual Sources of Infection for Persons with Hepatitis C Injecting drug use 60% Sexual 15% Transfusion 10% (before screening) Other* 5% Unknown 10% *Nosocomial; Health-care work; Perinatal Source: Centers for Disease Control and Prevention Posttransfusion Hepatitis C % of Recipients Infected All volunteer donors HBsAg Donor Screening for HIV Risk Factors Anti-HIV ALT/Anti-HBc Anti-HCV Improved HCV Tests Year Adapted from HJ Alter and Tobler and Busch, Clin Chem 1997 HCV Prevalence by Selected Groups United States Hemophilia Injecting drug users Hemodialysis STD clients Gen population adults Surgeons, PSWs Pregnant women Military personnel Average Percent Anti-HCV Positive HCV Testing Routinely Recommended Based on increased risk for infection • • • • • Ever injected illegal drugs Received clotting factors made before 1987 Received blood/organs before July 1992 Ever on chronic hemodialysis Evidence of liver disease Based on need for exposure management • Healthcare, emergency, public safety workers after needle stick/mucosal exposures to HCV-positive blood • Children born to HCV-positive women Routine HCV Testing Not Recommended (Unless Risk Factor Identified) • Health-care, emergency medical, and public safety workers • Pregnant women • Household (non-sexual) contacts of HCV-positive persons • General population HCV Infection Testing Algorithm for Diagnosis of Asymptomatic Persons Negative (non-reactive) STOP EIA for Anti-HCV Positive (repeat reactive) OR RIBA for Anti-HCV Negative STOP Negative Indeterminate Additional Laboratory Evaluation (e.g. PCR, ALT) Negative PCR, Normal ALT Positive PCR, Abnormal ALT Source: MMWR 1998;47 (No. RR 19) RT-PCR for HCV RNA Positive Medical Evaluation Positive HCV Counseling • Prevent transmission to others – Direct exposure to blood – Perinatal exposure – Sexual exposure • Refer to support group HCV Counseling Preventing HCV Transmission to Others Avoid Direct Exposure to Blood • Do not donate blood, body organs, other tissue or semen • Do not share items that might have blood on them – personal care (e.g., razor, toothbrush) – home therapy (e.g., needles) • Cover cuts and sores on the skin HCV Counseling Mother-to-Infant Transmission of HCV • Postexposure prophylaxis not available • No need to avoid pregnancy or breastfeeding – Consider bottle feeding if nipples cracked/bleeding • No need to determine mode of delivery based on HCV infection status • Test infants born to HCV-positive women – Consider testing any children born since woman became infected – Evaluate infected children for CLD HCV Counseling Sexual Transmission of HCV Persons with One Long-Term Steady Sex Partner • Do not need to change their sexual practices • Should discuss with their partner – Risk (low but not absent) of sexual transmission – Routine testing not recommended but counseling and testing of partner should be individualized • May provide couple with reassurance • Some couples might decide to use barrier precautions to lower limited risk further HCV Counseling Sexual Transmission of HCV Persons with High-Risk Sexual Behaviors • At risk for sexually transmitted diseases, e.g., HIV, HBV, gonorrhea, chlamydia, etc. • Reduce risk – Limit number of partners – Use latex condoms – Get vaccinated against hepatitis B – MSMs also get vaccinated against hepatitis A HCV Counseling Other Transmission Issues • HCV not spread by kissing, hugging, sneezing, coughing, food or water, sharing eating utensils or drinking glasses, or casual contact • Do not exclude from work, school, play, childcare or other settings based on HCV infection status HCV Has Broad Global Prevalence <1 % 1–2.4 % 2.5–4.9 % 5–10 % > 10 % No data available Hepatitis E Virus Hepatitis E - Clinical Features • Incubation period: • Case-fatality rate: Average 40 days Range 15-60 days Overall, 1%-3% Pregnant women, 15%-25% • Illness severity: Increased with age • Chronic sequelae: None identified Hepatitis E Virus Infection Typical Serologic Course Symptoms ALT IgG anti-HEV Titer IgM anti-HEV Virus in stool 0 1 2 3 4 5 6 7 8 Weeks after Exposure 9 10 11 12 13 Hepatitis E Epidemiologic Features • Most outbreaks associated with fecally contaminated drinking water • Minimal person-to-person transmission • U.S. cases usually have history of travel to HEV-endemic areas Geographic Distribution of Hepatitis E Outbreaks or Confirmed Infection in >25% of Sporadic Non-ABC Hepatitis Prevention and Control Measures for Travelers to HEV-Endemic Regions • Avoid drinking water (and beverages with ice) of unknown purity, uncooked shellfish, and uncooked fruit/vegetables not peeled or prepared by traveler • IG prepared from donors in Western countries does not prevent infection • Unknown efficacy of IG prepared from donors in endemic areas • Vaccine? نحوه برخورد با بيماران هپاتيتي شك به هپاتيت .1فاز مقدماتي زودرس ):(Prodromal تب ،آرترالژي ،آرتريت ،راش .2فاز قبل از ايكتر: بيحالي ،خستگي ،بياشتهايي ،درد عضالني ،تهوع ،استفراغ ،تغييرات بويايي و چشايي، عاليم شبيه سرماخوردگي در معاينه فيزيكي :هپاتومگالي ،لنفادنوپاتي زنجيره خلفي گردن 10ـ%5 .3فاز ايكتريك: اسكلرا و پوست زرد ،مدفوع كم رنگ ،ادرار تيره رنگ ،كاهش درجه حرارت بعد از شروع زردي .4فاز نقاهت: كاهش زردي بعد از چند هفته و بهبود عاليم عمومي آزمايشات درخواستي اوليه )ALT – AST – LDH – ALP – Bil (D-T PT مورفولوژي خون محيطي U/A اثبات هپاتيت با بررسي آنزيمهاي كبدي ALT 10ـ 8برابر AST انديكاسيونهاي بستري PT .1طوالني :بيشتر از 3ثانيه Bil .2افزايش يابنده بيشتر از 20 mg .3شواهد نارسايي كبد .4بي اشتهايي ,استفراغ هاي مكرر .5خانم حامله با سوءتغذيه شديد اثبات اتيولوژي عفوني دارويي توكسيك آنوكسي حاد كبد عوامل كمك كننده به تشخيص شرح حال اپيدميولوژي تست هاي آزمايشگاهي ماركرهاي سرولوژيك اثبات اتيولوژي عفوني دارويي توكسيك آنوكسي حاد كبد عوامل كمك كننده به تشخيص شرح حال اپيدميولوژي تست هاي آزمايشگاهي ماركرهاي سرولوژيك Suspicion of acute viral hepatitis based upon: • History, physical exam, epidemiologic situation •Elevated serum aminotransferase activity (ALT/AST) Diagnosis: Acute hepatitis A infection Anti-HBc IgM positive With or without HBsAg Diagnosis: Acute hepatitis B infection Anti-HCV positive Diagnosis: Acute HCV infection or exacebation of chronic HCV infection براي تشخيص يا اثبات اتيولوژي هپاتيت Obtain viral serologies: • Anti-HAV IgM •HBsAg and Anti-HBc IgM •Anti-HCV (EIA or RIBA) Anti-HAV IgM positive آزمايشات تكميلي Negative serologies Consider non-viral etiologies (e.g., Ischemia, toxins) or other infectious Etiologies (e.g., CMV, EBV) Check HBsAg and ALT/ AST in 6-9 months Consider possibility of HEV Infection if recent foreign travel Anti-HDV positive HBsAg positive with or without Abnormal aminotransferase Re-check anti-HCV In 3-6 months Diagnosis: HBV/HDV Co-infection Diagnosis: Chronic HBV infection Suspicion of HDV co-infection based on: • Risk factors (e.g., IVDA) • Clinical signs of severe hepatities Check anti-HDV درمان غيراختصاصي و پيگيري بيمار .1رژيم غذايي .2سرم قندي .3استراحت نسبي در بستر .4تست هاي آزمايشگاهي: T.A 2 .1هفته اول هفته اي 2بار 2 .2هفته دوم هفته اي 1بار بررسي HBS Agهر دوماه تا منفي شدن HBS Ag Needle Stick HBV 30% HCV 3% HIV 0.3% واكسيناسيون Can my baby die from hepatitis B? • Most babies do not die from hepatitis B. • Up to 9 out of 10 babies born to infected mothers will end up being hepatitis B carriers for the rest of their lives, if they do not get the shots. carriers • If you make sure your babies get all 3 shots, plus a shot called H-BIG, they have a 95% chance of being safe from hepatitis B for life. Baby Shots for Hepatitis B if the mother has Hepatitis B 1 - 2 months old Birth Hepatitis B Vaccine + Hepatitis B Vaccine H-BIG 6 months old Hepatitis B Vaccine Hepatitis B can be prevented! If you have never had hepatitis B, you can get 3 shots . . . 1 2 3 . . . and get long lasting protection. What if my baby does not get these shots? Up to 9 out of 10 babies born to infected mothers will end up being carriers for the rest of their lives, if they do not get the shots. Babies who end up as carriers have a 1 out of 4 chance of dying from liver problems. 19 out of 20 babies who get the shots will be protected for life! Hepatitis D - Prevention • HBV-HDV Coinfection Pre or postexposure prophylaxis to prevent HBV infection • HBV-HDV Superinfection Education to reduce risk behaviors among persons with chronic HBV infection Hepatitis A Prevention - Immune Globulin • Preexposure – travelers to intermediate and high HAV-endemic regions • Postexposure (within 14 days) Routine – household and other intimate contacts Selected situations – institutions (e.g., day care centers) – common source exposure (e.g., food prepared by infected food handler) Hepatitis A Vaccination Strategies Epidemiologic Considerations • Many cases occur in community-wide outbreaks – no risk factor identified for most cases – highest attack rates in 5-14 year olds – children serve as reservoir of infection • Persons at increased risk of infection – travelers – homosexual men – injecting drug users ACIP Recommendations - Hepatitis A Vaccine Preexposure Vaccination • Persons at increased risk for infection – travelers to intermediate and high HAV-endemic countries – homosexual and bisexual men – drug users – persons with chronic liver disease • Communities with high rates of hepatitis A (e.g., Alaska Natives, American Indians) Estimated Incidence of Acute Hepatitis B United States, 1978-1995 Cases per 100,000 Population 80 Vaccine licensed 70 HBsAg screening Infant of pregnant immunization women recommended recommended 60 OSHA Rule enacted 50 Adolescent immunization recommended 40 30 20 Decline among homosexual men & HCWs 10 0 Decline among injecting drug users * 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 * Provisional date Year • Postexposure Management for HCV for prophylaxis IG, antivirals not recommended • Follow-up after needlesticks, sharps, or mucosal exposures to HCV-positive blood – Test source for anti-HCV – Test worker if source anti-HCV positive • Anti-HCV and ALT at baseline and 4-6 months later • For earlier diagnosis, HCV RNA by PCR at 4-6 weeks – Confirm all anti-HCV results with RIBA • Refer infected worker to specialist for medical evaluation and management