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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 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 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: percutaneous (IV, IM, SC or intradermal) and permucosal exposure sexual transmission 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 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 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 Transmission is largely from infected blood or blood products 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 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 Sexual transmission between heterosexuals is very rare Incubation period is between 2 weeks and 6 months Most patients are asymptomatic 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 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