Download Hepatitis

Hepatitis
Recommend
 Provide vaccination to prevent hepatitis A and B, and advise avoidance of risk factors for hepatitis A, B
and C
 Provide vaccination for chronic hepatitis B and C patients who have not had hepatitis A or B
 Screen all patients who have tested positive for a sexually transmitted infection for hepatitis C
Background
 There are several forms of infectious hepatitis, caused by different viral agents. The most important
are hepatitis A, B and C
 Many hepatitis infections pass unnoticed especially hepatitis A and B in early childhood and C at any
age
 Signs and symptoms are often non-specific and a high degree of suspicion is needed to diagnose
these illnesses
 Hepatitis has many other possible causes such as alcohol use, drugs and other infections (glandular
fever, cytomegalovirus, Q fever, leptospirosis)
Related topics:
 Immunisation program, page 316
Hepatitis A
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Transmission is by the faecal-oral route and can occur sexually, especially in men having sex with other
men. May occur through eating food contaminated by infected food handlers
Outbreaks have been associated with injecting and non injecting drug use
Incubation period is between 2 weeks and 6 weeks (average 28 – 30 days)
The virus is excreted in the stools for two weeks before illness is apparent and continues for up to one
week after onset of jaundice
Symptomatic infection is most common in young adults. Severity of illness increases with age.
Childhood infection usually asymptomatic or causes a mild illness, but may be fatal
Close contacts require prompt protection with immunoglobulin
Vaccination should follow NHMRC ‘Australian Immunisation Handbook’ guidelines. See Immunisation
program
Notify all cases to the local Population Health Unit [1]
Hepatitis B
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There is a high incidence of hepatitis B in Aboriginal and Torres Strait Islander communities
Onset is usually insidious and may involve anorexia, abdominal discomfort, nausea and vomiting,
malaise and sometimes a rash and arthralgia. The illness may progress to jaundice
Transmission occurs by three major routes:
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percutaneous (IV, IM, SC or intradermal) and permucosal exposure
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sexual transmission
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perinatal transmission from mother to child at birth
Incubation period is between 6 weeks and 6 months (average of 60–90 days)
Complications include acute liver necrosis / failure, chronic hepatitis, cirrhosis and hepatocellular
carcinoma
Chronic carrier state develops in less than 5% of adult cases, but in 90% of neonates who contract the
virus
Carriers may go on to develop chronic hepatitis, cirrhosis or liver cancer
The blood and secretions of hepatitis B carriers are infectious
Vaccination should follow NHMRC ‘Australian Immunisation Handbook’ guidelines. See Immunisation
program
Notify all acute cases to the local Population Health Unit [1]
Chronic hepatitis B
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Only 30-50% of people with chronic hepatitis B will give a history of having acute hepatitis B in the past
Having hepatitis B surface antigen (HepBsAg) present is evidence of ongoing infection. Serology is
complex, and assistance should be sought in interpreting
Many patients are asymptomatic or have non-specific symptoms such as fatigue
Laboratory tests may be normal, but most patients have AST and ALT elevation
Patients with decompensated cirrhosis, they may present with jaundice, ascites, peripheral oedema, and
encephalopathy
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Progression to cirrhosis is suspected when there is evidence of hypersplenism (decreased white blood cell
and platelet counts) or impaired hepatic synthetic function (low serum albumin, prolonged prothrombin
time, raised bilirubin level)
Management of Chronic Hepatitis B
 Once chronic hepatitis B has been confirmed, follow-up with annual LFTs
 Advice to cease / reduce alcohol intake should be given
 Treatment of chronic hepatitis B with medications, may cause loss of hepatitis B surface antigen. A liver
biopsy is required prior to treatment
 Close contact including steady sexual partners of people with hepatitis B should be tested for hepatitis B,
and if negative, should be vaccinated
 Patients with chronic hepatitis B should be vaccinated against hepatitis A
Management of Cirrhosis
 Patients with cirrhosis should be screened 6-monthly with alpha fetoprotein (αFP) and liver ultrasound to
allow early diagnosis of hepatocellular carcinoma (liver cancer)
 Early detection and treatment of this cancer can lead to an improved outcome
Hepatitis C
Recommend
 Provide treatment for 6 or 12 months (depending on the strain of hepatitis C)
 Screen all patients who have tested positive for a sexually transmitted infection for hepatitis C
Background
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Transmission is largely from infected blood or blood products
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20% of IV drug users will acquire hepatitis C within their first two years of use, whilst almost 95% will
be infected after 10 years of use
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7-16% of those with hepatitis C will go on to develop cirrhosis within 20 years of infection
 those with cirrhosis may go on to develop liver failure, and/or carcinoma
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Sexual transmission between heterosexuals is very rare
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Incubation period is between 2 weeks and 6 months
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Most patients are asymptomatic
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About 20% of those infected will spontaneously clear the virus within the first 6-12 months. The
remainder become chronic carriers. In any patient with antibodies to hepatitis C, a hepatitis C PCR
test (and liver function tests) must be performed to determine whether or not the infection is still
present
Related topics:
Hepatitis A and B, page 321
1.
May present with:
 Asymptomatically and are found to be positive on testing. This is the most common way to be
diagnosed
 Jaundice, anorexia, nausea, lethargy and upper abdominal pain occur uncommonly in acute hepatitis
C
2.
Immediate management: not applicable
3.
Clinical assessment:
 Obtain comprehensive patient history - specifically ask
 about the possibility of contact with others with the disease
 medication history (including regular and occasional, prescription and non-prescription,
complementary or bush medicine)
 alcohol use
 IV drug use
 Perform standard clinical observations + urinalysis for bilirubin or urobilinogen
 Perform physical examination - inspect for jaundice and palpate the abdomen for a tender / enlarged
liver
4.
Management of Hepatitis C:
 Annual monitoring of LFTs should be performed if have chronic hepatitis
 Hepatitis C patient should be encouraged to cease / reduce drinking alcohol
 Hepatitis C patients should be tested for both hepatitis A and B and vaccinated if found to be
negative
 Treatment with either 6 or 12 months of medications (depending on the strain of hepatitis C) can
cure 55-85% of people with hepatitis C
 a liver biopsy is not required prior to starting treatment
 there are numerous side-effects – some potentially life-threatening from the treatment
 For patients with cirrhosis, refer to management in the hepatitis B section
4.
Management of acute viral hepatitis A, B, or C (see previous)
 Consult MO
 Will require evacuation/hospitalisation if severe illness
 Otherwise, treatment of hepatitis is supportive and symptomatic
 Diagnosis is confirmed with serology for hepatitis A, B and C
 Send blood for liver function tests (LFTs)
 Bed rest is advised if the patient has jaundice
 Avoid alcohol (and paracetamol during acute illness)
 Educate the patient and household contacts on transmission of the virus and the appropriate
preventive measures
 Food handlers and child care workers with proven or presumed hepatitis A should not work for at
least 1 week from the onset of jaundice
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Active immunisation (Hepatitis A and B) should occur if appropriate in consultation with MO or
Population Health Unit
5.
Follow up:
 Review in 24 hours and repeat education
 Contact tracing and passive immunisation against hepatitis A with immunoglobulin (as early as
possible and within two weeks of contact) should occur in consultation with MO or Population Health
Unit
6.
Referral / Consultation:
 Consult MO on all occasions jaundice detected or hepatitis is suspected
 Notify all cases of hepatitis A and acute cases of hepatitis B to the Population Health Unit
 Referral to Specialist services
 See Queensland Health Fact Sheets
http://access.health.qld.gov.au/hid/InfectionsandParasites/ViralInfections/hepatitisA_fs.asp
http://access.health.qld.gov.au/hid/InfectionsandParasites/SexuallyTransmittedDiseases/hepatitisBS
exualHealthContacts_fs.asp
http://access.health.qld.gov.au/hid/InfectionsandParasites/ViralInfections/hepatitisC_fs.asp
 See NSW Fact Sheets for Head Lice, Scabies, Hepatitis A, Hepatitis B, Hepatitis C and Meningitis
www.health.nsw..gov.au/pubs/type/factsheets.html