Download Hepatitis and Co-infection with HIV

The Alphabet Soup of Viral Hepatitis
Stephen J. Gluckman, M.D.
Hepatitis
“itis” in the “hepar”
Hepatitis: causes
Drugs
Toxins
Vasculitis
Vascular
CHF
Shock
Metabolic
Infectious
Bacterial
Parasitic
Fungal
Rickettsial
Viral
EBV
CMV
A,B,C,D,E,(f),G
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.
Viral Hepatitis
Transmission
Clinical disease
Diagnosis
Treatment
Prevention
Health care risk
HEPATITIS A VIRUS
GEOGRAPHIC DISTRIBUTION OF
HEPATITIS A VIRUS INFECTION
Anti-HAV Prevalence
High
High/Intermediate
Intermediate
Low
Very Low
Hepatitis A: transmission
Fecal-Oral


Contaminated food and water
Person to Person
Minimal or no risk factor



Blood
Maternal-Fetal
Needle stick
HEPATITIS A, UNITED STATES
Most disease occurs in the context of
community-wide outbreaks
Infection is also transmitted from person to
person in households and extended family
settings

facilitated by asymptomatic infection among
children
No risk factor identified for 40%-50% of
cases
Hepatitis A: clinical disease
Often sub-clinical
Incubation period: 2 - 6 weeks

Average 30 days
Acute, self-limited illness
Rarely fulminant
No chronic sequellae
EVENTS IN HEPATITIS A VIRUS INFECTION
Clinical illness
Infection
ALT
Response
IgM
IgG
Viremia
HAV in stool
0
1
2
3
4
5
6
Week
7
8
9
10
11
12
13
Hepatitis A: diagnosis, treatment and
prevention
Diagnosis: IgM for acute infection

IgG for past infection
Treatment: supportive

There is no specific anti-viral for hepatitis A
Prevention




Safe water
Hand washing
Pre-exposure: vaccine
Post-exposure: vaccine has replaced
immune globulin
Health Care Workers and
HAV
Minimal risk
 Fecal-oral: therefore
 The most important thing for the patient to do
is to use the bathroom and wash hands
 The most important thing for the HCW to do is
wash hands
Prevention recommendation for HCW
 Know your HAV antibody status
 IF (+): protected
 IF (-): get vaccinated
Hepatitis B Virus
Hepatitis B: transmission
Incubation period: 6 weeks to 6 months
Perinatal
 The most common mode of transmission in
the developing world
Sexual
 The most common mode of transmission in
developed countries
Parenteral


Blood products
IVDA
Hepatitis B: natural history
Acute HBV Infection in
Adults
90%
10%
Chronic
Resolves
30%
70%
Benign
Cirrhosis
HCC
Death
Geographic Distribution of Chronic HBV
Infection
HBsAg Prevalence
8% - High
2-7% - Intermediate
< 2% - Low
Hepatitis B: testing
What do they all mean?
HBsAG: surface antigen
Anti-HBsAG
HBcAG: core antigen
Anti-HBcAG


IgM
IgG
HBeAG: e antigen
Anti-HBeAG
HBV DNA (viral load)
Hepatitis B Serology
HBsAG
NEG
NEG
NEG
POS
POS
NEG
NEG
POS
POS
NEG
NEG
NEG
IgG AntiHBc
NEG
POS
NEG
POS
POS
POS
IgM AntiHBc
NEG
NEG
NEG
NEG
POS
NEG
Anti-HBs
SUSCEP Immune:
PAST
INFECT
Immune: CHRONIC RECENT SEVERAL
VACCINA- CARRIER INFECT POSSIBIL
TED
-ITIES
Hepatitis B: diagnosis
Clinical Disease
ANTI-HBSAG
Titer
HBSAG
“Window”
IGM ANTI-HBCAG
Exposure
Time
(month)
Hepatitis B: treatment
There are many effective options






Lamivudine (Emtricitabine)
Tenofovir
Adefovir
Entecavir
Telbivudine
Interferon
Hepatitis B: prevention
Pre-exposure (A MUST FOR ALL!)


Vaccine made by recombinant technology
Only HBsAG – no risk of transmission
Post-exposure


HBIG
Vaccinate
Eliminating HBV in the United
States: Strategy
Prevent peri-natal HBV transmission
Routine vaccination of all infants
Vaccination of adolescents
Vaccination of adults in risk groups
Hepatitis B and Pregnancy
No need to avoid pregnancy
Neonate should get HBIG and Vaccine
No need to alter mode of delivery
Hepatitis B and Sexual Partners
If monogamous

Partner should be tested
 If (-) vaccinate
If non-monogamous

Condoms
Health Care Workers and HBV
Potentially high risk from needle stick type
injury
THERE IS NO REASON FOR ANY RISK!
Recommendation: Get tested (antiHBsAG) and get immunized (or just get
immunized if test not available)
Hepatitis B
HCW Needle Stick Management
Check titer




If (+) nothing else is necessary
If (-)
History of vaccination
 Give a single booster
No history of vaccination
 HBIG and Vaccine
Hepatitis C Virus
Hepatitis C
Transmission
IVDA
 Major cause in the USA
 % (+) after 1 year of using
 HCV 65, HBV 50, HIV 14
Blood transfusion
 Very low risk today
Sex
 Very low risk: 0.1%/yr for spouse of known positive
 Higher risk with more partners
Unknown: up to 40%
HCW Needle stick: 1.8%
Perinatal: 5%

Higher with HIV co-infection
Breast Milk: no identified risk
Hepatitis C: natural history
Acute Infection
80 %
20 %
Chronic Infection
Rate of Progression
Resolution
Slow
Intermediate
Rapid
30% of all with chronic infection
Cirrhosis
2-5 %
HCC
DEATH
Hepatitis C: clinical course
Incubation period: 4 - 8 weeks
Acute disease generally sub-clinical or
mild
Poor correlation between liver
transaminases and histology

Prognosis best based on histology
Chronic Hepatitis C
Factors Promoting Progression or Severity
Alcohol intake


Even a little alcohol intake
Miniscule amounts of alcohol intake
Age > 40 years at time of infection
HIV co-infection
Other


Male gender
Chronic HBV co-infection
Laboratory Pattern of Acute HCV Infection
with Progression to Chronic Infection
anti-HCV
Exposure
Symptoms +/-
Titer
HCV RNA
ALT
Normal
0
1
2
3
4
Months
5
6
1
Time after
Exposure
2
3
Years
4
Hepatitis C
Diagnosis


IgG screen
 Can take months to become positive
If IgG is (+) then must get viral load
Management



Vaccinate for Hepatitis A and B
Counsel about alcohol avoidance
Consider treatment with pegylated interferon and
ribavirin
 Response rates about 50%
Prevention


No vaccine
Clean needles
Hepatitis C and Pregnancy
No need to avoid pregnancy or breast
feeding
Post exposure prophylaxis is not
available
No need to alter mode of delivery
Test infant and 15-18 months
Hepatitis C and Sexual Partners
If one long-term steady partner


No need to change sexual practices
May choose to use condoms
If multiple partners


Remind them that they are at risk for other
STD’s
Use condoms
Occupational Transmission of
HCV
Inefficient transmission by occupational
exposure

Prevalence 1-2% among health care workers

Not higher than adults in the general population
Average incidence 1.8% following needle stick
from HCV-positive source

Associated with hollow-bore needles
Case reports of transmission from blood splash
to eye; one from exposure to non-intact skin
Hepatitis C
HCW Needle Stick Management
No post-exposure prophylaxis available
Check HCW HCV Antibody
If HCV antibody (-)



Recheck antibody at 3 and 6 months
OR
Check HCV PCR at 1 month
If either (+) consider treatment with
pegylated interferon and ribavirin
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,
child-care or other settings based on
HCV infection status
Hepatitis D (delta) Virus
d antigen
HBsAg
RNA
Hepatitis D (HDV)
Defective pathogen that REQUIRES
co-infection with hepatitis B


Simultaneous acute infection
 Severe acute disease
 Low risk of chronic disease
Superimposed on chronic HBV infection
 Usually develop chronic hepatitis D also
 Severe chronic liver disease
Geographic Distribution of HDV Infection
Taiwan
Pacific Islands
HDV Prevalence
High
Intermediate
Low
Very Low
No Data
Hepatitis D
Transmission: Sex, blood
Clinical: acute and chronic, but only in
the presence of co-infection with
hepatitis B
Diagnosis: serology
Treatment: treat B
Prevention: prevent B
Health care risk: unclear
Hepatitis E Virus
Geographic Distribution of
Hepatitis E
Hepatitis E – Clinical Features
Transmission: fecal-oral


Drinking water
USA cases have history of travel to endemic
areas
Incubation period

15-60 days
Fatality 1%

*Pregnant women 15%-25%
Chronic Sequellae: none in most people

Case reports of chronic hepatitis in organ
transplant recipients
Hepatitis E
Diagnosis: serology
Treatment: supportive
Prevention: avoid unsafe water


No evidence that IgG works
No vaccine
Health care worker risk: minimal
Hepatitis G
Global distribution
Spread similar to HCV
30% homology with HCV
Not pathogenic in humans
Protective if co-infection with HIV


Decreased mortality
In vitro decreased HIV production
Viral Hepatitis - Summary
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
yes
yes
no
pre/postpre/postblood donor
pre/postensure safe
exposure
exposure
screening;
exposure
drinking
immunization immunization risk behavior immunization;
water
modification risk behavior
modification
Summary
Patient

Consider Hepatitis A and B immunization for all
patients
HCW Risks From a Needle Stick
 HAV: minimal
 HBV: 30%
 HCV: 1.8%
 HDV: ?
 HEV: minimal
 HGV: none known
 (HIV: 0.3%)
Questions?