Download Hepatitis A, B, C Screening

HEPATITIS A, B, C SCREENING
Valerie Dzubur EdD APRN FNP-BC
HEPATITIS A SCREENING
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Hepatitis A is a acute self limited illness with inflammation of the liver
Reportable to the Public Health Department
Passed by the fecal – oral route
Highest HAV titers are 1 – 2 weeks before onset of the illness
70 % of adults and children > 6-yrs old will have jaundice
Fulminant hepatitis from A is rare
Duration of illness is typically 8 weeks but can go on for 6 mos
Prevention is vaccination, hand washing after BR & diaper change
Use Immune globulin IgG for exposure
HEPATITIS A SCREENING
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Risk Factors
Ingestion of infected food or water and shellfish
Close personal contact with infected person
Pregnancy with vertical transmission
Travel to endemic area
Crowded living conditions
Poor sanitation
Poor hygiene
HEPATITIS A SCREENING
• Prevention
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Hepatitis A vaccination for everyone
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Havris and Vaqta are available in the US, 2 injections six months apart
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Immune globulin IG for exposure
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Hand washing to prevention infection
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Testing – HAV, IgG and IgM
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Other testing in presence of infection
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LFT, Bilirubin, CBC, PT, UA
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Consider testing for hepatitis B and C
HEPATITIS A
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Differential Diagnosis
Mono
Cancer
Obstructive jaundice
ETOH hepatitis/cirrhosis
Hepatotoxic drug use
Food poisoning
Cytomegalovirus
Acute HIV infection
Hepatitis B/C
HEPATITIS A
• Infected persons should stay home from work, school or child care for 1
week after symptoms after the onset of symptoms
• Education to stress hand washing after BR, before food preparation
• Encourage optimum nutrition
• Rx vomiting
• Prevent dehydration with fluids
• Vaccinate close contacts with Immune globin IG
• The elderly are at highest risk for a bad outcome follow closely
HEPATITIS B SCREENING
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Caused by Hepatitis B Virus (HBV) a hepadnavirus
Required reporting to public health department
Incubation period is 45 – 160 days
An infected person can spread the disease 4 – 6 weeks before symptoms and an
unpredictable period of time after infection
The virus can live 1 week on contaminated objects
Diagnosis is by laboratory analysis
Testing is done to determine conversion and/or disease stage
Acute Infection
Chronic Active Infection
Chronic carrier of Infection
Eight genotypes have been identified
Antiviral treatment may be effective in 1/3 of cases
Consider referral to GI for typing and Rx
HEPATITIS B SCREENING
• Hepatitis B is the main cause of cirrhosis and liver cancer world wide
• Prevention
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Hepatitis B Vaccination 3 shots 1,2, 6 months starting at birth
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HBIG for post exposure prevention
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Condoms
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Avoid needle sharing
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Primarily passed through IVDU, unprotected sex, vertical transmission at birth
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Highest concentration of the virus is in blood and blood serum
HEPATITIS B SCREENING
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Risk Factors
IVDU
Asian, Hispanic, Eskimos, Asian Pacific Islanders, Australian aborigines
Men who have sex with men
Previous STI
Sex workers, multiple sex partners, unprotected sex with unknown status
Pregnancy in HBag + person, mother with + HCV
Can be spread through breast feeding unless neonate is vaccinated
Should receive HBIG within 12 hrs of birth in Hbag + mothers
Blood transfusion for hemophilia, hemodialysis
International travel, history of a blood transfusion
Incarceration
Tattoos or other percutaneous contact
HEPATITIS B SCREENING
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Testing
HBsAg – Hepatitis B surface antigen
Anti-HBs – Antibody to HBsAg
ABeAg – Hepatitis B e antigen
Anti-HBe – Antibody to HBeAg
Anti-HBc – Antibody to hepatitis B core antigen; IgM (HBcAg)
IgM anti HBc – IgM antibody to HBcAg
HEPATITIS B SCREENING
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HBsAg- Detects acutely/chronically infected persons
Anti-HBs- Identifies resolved HBV infections, immunity from vaccination
HBeAg -Identifies at-risk of transmitting HBV
Anti-HBe- Identifies lower-risk of transmitting HBV
Anti-HBc- Identifies acute, resolved, or chronic HBV infection, is not
present after vaccination
• IgM anti HBc- Identifies acute or recent HBV infections, even if HBsAg is
negative because it is during the early window or phase of infection
• IgM subtype – acute or reactivated infection
• IgG subtype – indicates chronic infection
HEPATITIS B SCREENING
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USPSTF recommends screening by risk groups
Ethnicity Asian, Eskimo, Pacific Islander
IVDU
Sex Workers
Men who have sex with men
Pregnancy
Household Exposure of unvaccinated persons to HBAg+ person
Persons with elevated LFTs (include screen for A & C)
Unvaccinated healthcare workers
Non-convertors to the vaccination case by case
You do not need to test for HBV before vaccination risk/benefit
HEPATITIS B SCREENING
HBV positive education
Counsel to avoid ETOH use
Tylenol
Statins
Vaccinate for A
HEPATITIS B SCREENING
• Post exposure Hepatitis B Prophylaxis after percutaneous exposure when
source is HBsAg positive
• Unimmunized
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Initiate Hep B vaccination, give HBIG
• Previously immunized non-responder
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Revaccinate Hep B series, give HBIG
• Previously immunized response unknown
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Test exposed person for anti-HBs and administer vaccine booster dose, schedule
additional 2 doses to complete a 3 dose re-immunization series
HEPATITIS C SCREENING
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HCV infection often undistinguishable from HBV infection
Tends to be asymptomatic or mild infection
The hidden epidemic – required reporting to the public health department
Has a propensity to become chronic
70 – 80 % of infected persons will have chronic infection
20 % will develop cirrhosis
There are multiple genotypes and subtypes – liver biopsy
HCV is the leading cause of nonalcoholic hepatic failure and cirrhosis
Hepatocellular carcinoma is dx in 1 – 5 % of people 30-yrs after infection
1.3 % of US population is HCV positive
HEPATITIS C SCREENING
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Testing
HCV IgG antibody enzyme immunoassay to detect RNA
If positive consider
HCV genotyping
HCV viral load
LFTs
Hepatitis A and B
Test for Hepatitis B & C and vaccinate as indicated
CMV IgM and IgG
Epstein-Barr virus IgM and IgG
HIV - ELISA
Alpha-fetoprotein
Refer to Hepatology Specialist in HCV
HEPATITIS C SCREENING
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USPSTF guidelines – screen by high risk groups
IVDU, tattoos, acupuncture, body piercing, use of unsterile equipment
Children born to HCV + mothers
Multiple sex partners
Men who have sex with men
No condom with partners of unknown status
Sex workers, multiple partners
Blood Transfusion before 1992
History of illegal drugs use including cocaine and pot – sharing equipment
Sharing household tools with known + person e.g. tooth brush
Healthcare workers with percutaneous exposure
HEPATITIS C SCREENING
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Education
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Avoid ETOH
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Avoid Tylenol
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Avoid Statins
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Get vaccinated for A & B
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Steady partners of known + persons don’t need to change sex practice but should be informed of risk
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Consider number of sexual partners, use condoms
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Avoid IVDU, use of other drugs with HCV + persons, include drug use equipment
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If pregnancy is planning inform prenatal provider of + HCV status
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Not contraindicated in breast feeding but abstain if nipples cracked or bleeding
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Avoid blood and organ donation
HEPATITIS A,B, AND C
SCREENING
In conclusion
Infection from Hepatitis A,B, and C is preventable
Vaccinate everyone for Hepatitis A and B
Avoid risky behavior, use protection
Treat exposure right away
Refer for treatment for infection
Screen all at risk people
Educate your patients