Transcript 17 - ACUTE VIRAL HEPATITIS.ppt

ACUTE VIRAL HEPATITIS
CLINICAL PRESENTATION.
DIGNOSIS.
EPEDEMOLOGY OF VIRAL
HEPATITIS INFECTION A,B,C IN
KSA.
MANAGEMENT.
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
pre/postexposure
immunization
yes
yes
yes
pre/postblood donor
pre/postexposure
screening;
exposure
immunization risk behavior immunization;
modification risk behavior
modification
no
ensure safe
drinking
water
Diagnosis of hepatitis
Patient history
Physical examination
Liver function tests
Serologic tests
Symptoms and Signs
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Pre-icteric phase
Anorexia
Fatigue
Nausea
Vomiting
Arthralgia
Myalgia
Headache
Photophobia
Pharangitis
1.
2.
3.
4.
5.
Icteric phase::
Enlarged liver
Tender upper quadrant
Discomfort
Splenomegaly (10-20%)
General adenopathy
Post-icteric phase
Lab Findings
L FT increase >5-10 times of normal
2. Markers of hepatitis B or C or A might be
positive
1.
Pathological findings
1. Pan lobular infiltration with mononuclear
cells
2. Hepatic cell necrosis
3. Reticulum framework are intact
DD:
1.
2.
3.
4.
5.
Infectious Mononucleosis
Drug Induced Hepatitis
Chronic Hepatitis.
Alcohol Hepatitis
Cholecystitis, Cholelithiasis
Complications
1.Chronic hepatitis 
2.Fulmnant hepatitis
cirrhosis- HCC
FULMINANT HEPATITIS
Definition: Hepatic Failure Within 8 Weeks
Of Onset Of Illness.
Manifestation: Encephalopathy and
Prolonged PT
Histopathology: Massive Hepatic Necrosis.
Hepatitis B - Clinical Features
• Incubation period:
• Clinical illness (jaundice):
• Acute case-fatality rate:
• Chronic infection:
• Premature mortality from
chronic liver disease:
Average 60-90 days
Range 45-180 days
<5 yrs, <10%
5 yrs, 30%-50%
0.5%-1%
<5 yrs, 30%-90%
5 yrs, 2%-10%
15%-25%
HBV infection
Factors affecting transmission ability
1.Replicative status
- HBeAg
- high HBVDNA
2.Route of infection
- percutanouse
- Transmucosal
3. Exposure frequency : Single vs. Multiple
4. Inoculums size : transfusion vs. needle stick
Hepatitis B
Hepatitis B serology
anti-HBc exposure (IgM = acute)
HBsAg  infection (carrier)
anti-HBs  immunity
HBeAg  viral replication
anti-HBe  seroconversion
HBV-DNA  viral replication
Natural History
Gow, BMJ 2001
Hepatitis B Virus
Modes of Transmission
• Sexual
• Parenteral
• Perinatal
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
Possible transmission route of HBV
in KSA
1-Horisontal transmission (person to person) is the main
transmission route
2-Perintal transmission (positive HBSAG mothers)
especially if they are HBEAG positive
3- Heterosexual transmission
4-Illegal injection drug use
5- Contaminated equipment used for therapeutic
injections and other health care related procedures
6- Folk medicine practice
7-Blood and blood products transfusion without prior
screening
HBV INFECTION
before and after
vaccination program
OVERALL PREVALENCE OF HBsAg AMONG
SAUDIS IN THE 80’S ACCORDING TO REGIONS
10
9.6
8.9
8.3
Positivity (%)
8
6
5.5
4
2
0
Central (n=6649) South-western
(n=7235)
Eastern
(n=8300)
Total (n=32183)
Al-Faleh. Annals of Saudi Medicine, 1988
PREVALENCE OF HBeAg AMONG HBsAg POSITIVE
SAUDIS PREGNANT WOMEN (n = 20920)
6
5.4
5
4
3.7
3
2
1
0
% of HBsAg pos.
% of HBeAg Pos.
Al-Faleh, Annals of Saudi Medicine, 1988
FREQUENCY OF HBeAg AMONG HBsAg
POSITIVE SAUDI CHILDREN (n=307)
19.4
19.5
19
Percent
18.5
17.9
18
17.5
17.2
17.1
17
16.5
16
15.5
1-3 years
(93/16)
4-6 years
(103/20)
7-10 years
(111/19)
Total
(307/55)
Al-Faleh et al. Journal of Infection, 1992
PREVENTION STRATEGIES OF
MINISTRY OF HEALTH IN KSA
Introducing HBV vaccine in EPI program; and
Mandatory screening of blood donors
and expatriates.
Vaccination of risk groups.
Health education especially among
medical personnel.
THE CURRENT EPI IN THE
KINGDOM OF SAUDI ARABIA
1.
2.
3.
4.
5.
6.
7.
8.
At birth
At 6 weeks
At 3 months
At 5 months
At 5months
At 12 months
At 18 months
At 4-6 years
BCG +
DPT1 + OPV1
DPT2 + OPV2
DPT3 + OPV3
Measles
MMR
(DPT + OPV)
(DPT + OPV)
HB1
Hb2
HB3
Booster 1
Booster 2
COMPARISON OF PREVALENCE OF HBsAg
AMONG SAUDI CHILDREN IN 1989 (n=4575)
AND 1997 (n=5355) – ACCORDING TO AGE
10 9.68
7.57
7.24
6.54
6
7.2
6.71
6.51
6.35
6
5.81
5.06
4
2.31
Total
12
11
10
7
0.31
0
9
0.2
0
8
0
6
0.16 0.3
0.82 0.93
5
0
4
0
3
0
2
2
1
Percentage
8
(Age in years)
Al Faleh, J Infect 1999
1989
1997
COMPARISON OF PREVALENCE OF HBsAg
AMONG SAUDI CHILDREN IN 1989 (n=4575)
AND 1997 (n=5355) – ACCORDING TO REGION
13
12.67
10.29
9 8.63
7.59
7.53
6.71
5.83 5.71
5.22
5
1989
0
0.31
Total
0.3
Taif
0
Jeddah
0.47
Dammam
0
Tabouk
0
Al-Jouf
Gizan
Al-Baha
0
Najran
0.77
0
Aseer
0
Medina
0.52
3.73
1.52
0.83
Makkah
0
Qassim
1
3.14
2.87
Hail
3.48
3
-1
9.04
8.83
7
Riyadh
Percentage
11
1997
Al Faleh, J Infect 1999
Prevalence Of HBsAg Among Saudi Population
Before & After Vaccination over 18 y
10%
8%
Before
6.70%
After
6%
4%
2%
0%
1989
1-10yr
Age
numbers 4575
0%
1992
1-2yr
637
0.16%
1997
1-12yr
3666
0%
2007/8
16-18yr
1365
Long Term Seroconversion Rate Over
18 Years (Anti-HBS)
100%
95%
80%
*
77% **
60%
60%
***
40%
20%
0%
1992
Age
N
1-2yr
637
1997
1-12yr
3666
2007/8
16-18yr
1365
* Al Faleh et al Annals of Saudi meds 19
** Al Faleh et al Journal of infection 19
*** AlFaleh et al journal of infection200
CHANGING PATTERNS OF HBsAg POSITIVITY
AMONG BLOOD DONORS IN MOH,CENTRAL
BLOOD BANK 1994-2005
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
4.4
3.25
1.5
1994
n=9690
2000
n=91695
2005
n=177037
PREVALENCE OF HBsAg POSITIVITY AMONG
BLOOD DONORS IN KKUH FROM 1987 TO 2008
5
4.7
4.5
Positivity %
4
3.5
3
3
2.5
2
1.5
1
1.97
1.4
1.7
2
2.2
1
1
0.8 0.78 0.65
0.5
0
5 ) 91 ) 85 ) 85 ) 31 ) 93 ) 72 ) 46 ) 61 ) 56 ) 64 ) 67 )
6
3 5 = 1 9 = 6 8 = 6 2 = 6 0 = 4 7 = 5 4 = 9 1 = 8 3 =9 1 = 8 6 = 9 6
n=
(n
(n
(n
(n
(n
( n 4 ( n 5 (n 6 ( n
( n 8 (n
(
7
1
6
7
8
2
3
7
8
9
9
9
9
0
0
00 200 200 00 200
9
9
9
9
9
0
0
2
1
1
1
1
1
2
2
2
HBSAg positively Among Blood donors
in KKUH ( 18-21y)
1.4
1.24
positivity %
1.2
1
0.8
0.6
0.6
0.6
0.4
0.2
0
2000 n= 647
(18- 20)
2004 n=1371 2005 n=1504
(18-20)
(18-21)
HCV INFECTION
Transmission of HCV
EGYPT, mass campaigns of parenteral
antischistosomal therapy(discontinued
only in the 1980 ) may represent the
WORLD, largest iatrogenic transmission of
BLOOD BORNN PATHOGENS
frank c,Moh m k et all lancet 2000
Natural history
Marcellin, J Hepat 1999
COMPARISON OF PREVALENCE OF ANTI-HCV IN
SAUDI CHILDREN IN 1989 AND 1997 STUDIES
1989
1997
No. of children
Positive (%)
No. of children
Positive (%)
4496
39
(0.87%)
5350
2
(0.04%)
Diagnostic test only by
1st-generation EIA kit.
Diagnostic test by
3rd-generation EIA kit and
confirmatory test by RIBA
kit.
Overall prevalence rate of HCV infection in KSA
among children and adolescent during the last
18 yrs.
1989
1997
2008
No. of
children
Positive (%)
No. of
children
Positive
(%)
4496
39*
(0.87%)
5350
2**
(0.04%)
Diagnostic test
only by
1st-generation EIA
kit.
No. of
students
1357
Positive (%)
(5)3
0.22%
Diagnostic test by
Diagnostic test by
PCR for anti- HCV
rd
3 -generation EIA
Positive cases.
kit and confirmatory
test by RIBA kit.
* ALFaleh et al. Hepatology 1991
** ALFaleh Ann Saudi Med. 2003
Prevalence of HCV Among Saudi
Blood donors (1998- 2002)
1.4
1.2
1.3
1.2
Precentage
1
1.2
0.9
0.8
0.7
0.6
0.4
0.2
0
1998
(n=104003)
1999
(n=110608)
2000
(n=114122
2001
(n=115090)
2002
(n=113993)
Shobokshi et al , SMJ 2003
HCV positivity among blood donors in 2005 in
central blood bank of MOH in KSA according to
regions
0.6
0.6
0.5
0.5
0.4
0.4
0.3
0.3
0.3
0.3
0.2
0.2
0.2
0.1
0.1
0
a
iy
)
65
72
)
)
94
=1
74
60
l(n
96
ta
=2
(n
=2
To
(n
m
e
ee
nc
as
ie
lq
ov
A
Pr
n
re
)
st
14
Ea
53
=
(n
)
n
50
za
27
Je
=1
(n
n
8)
ra
84
aj
N
=9
(n
a
)
ah
40
lb
08
A
2
=
)
(n
48
er
33
se
A
=2
(n
h
)
ka
68
ak
12
M
=3
(n
dh
R
HCV positivity among Saudi blood donors from
1996 – 2005 in KKUH (n=58910)
Percentage
0.8
0.58 0.55
0.6
0.36
0.4
0.2
0
0.28 0.3
0.22
0.3
0.14
0.2
1996 1997 1998 1999 2000 2002 2003 2004 2005
(n=40) (n=35) (n=22) (n=13) (n=18) (n=15) (n=17) (n=11) (n=19)
KKUH Blood bank
HCV POSITIVITY AMONG SAUDI BLOOD DONORS
FROM 1996 TO 2000 IN KKUH
ACCORDING TO AGE GROUPS
5
4.4
Percentage
4
3
2
1
0.53
0.69
30-40
40-50
0.38
0.17
0
20-30
> 50
Total
(Age in years)
No. of blood donors = 32793
KKUH Blood bank
Prevalence of HCV Positivity
Among Different Saudi population
Type of patient
number
Prevalence(%)
Children from 1-18y
3854
0.1
Pregnant women
3127
0.7
Hemodialysis patients
29054
55.8
Drug addicts
9137
14
Shobokshi et al , SMJ 2003
Prevention Of HCV Transmission
Avoiding shared use of Razors or brushes
and any item that pierces the skin.
Strict adherence of the universal
precautions in health facilities.
Educating and training of HCW’s to the
proper use of standard precautions
Folk medicine?!
Acute HCV Infection: Summary
1. Symptomatic patients may clear HCV
2. Spontaneous clearance usually
occurs by 6 weeks, almost always by 12
weeks
3. Start treatment for asymptomatic
infections at 8weeks
Start treatment for symptomatic infections
if still positive at 8weeks
4. Standard dose of PEG-IFN weekly x 24
weeks will achieve SVR in 85%-100%
HAV INFECTION
COMPARISON OF PREVALENCE OF ANTI-HAV AMONG SAUDI
CHILDREN IN 1989 (n=4375) AND 1997 (n=5255) – ACCORDING
TO AGE
80
72.6
Percentage
70
60
59.8 59.7
48.5 54.1
50
41.6
40
48.850.5
43.9
34.8
30 23.7
20
10
63.5
13.4
17.6
20.3
23.4
24
26.7 28
30.6
33.1 34.5
26.4
24.9
0
1
3
5
7
9
11
Total
(Age in years)
1989
1997
Al-Faleh et al. Saudi Med. J, 1999
82.2
81.6
79.1
62.7
56
55
59.5
76
64.4
51.3
39
44.5 43.6
31.6
28.2
20.4 20.1
16.1
47.9 45.6
38.4
51.1
50.5
25.4
24.9
19
18.2 17.5 19
1989
1997
Total
Taif
Jeddah
Dammam
Tabouk
Al-Jouf
Najran
Gizan
Al-Baha
Aseer
Medina
Makkah
Hail
9.6
Qassim
91
81
71
61
51
41
31
21
11
1
Riyadh
Percentage
COMPARISON OF PREVALENCE OF ANTI-HAV
AMONG SAUDI CHILDREN IN 1989 (n=4375) AND
1997 (n=5255) – ACCORDING TO REGION
Percentage
COMPARISON OF PREVALENCE OF ANTI-HAV
IN ASEER REGION AMONG SAUDI CHILDREN
IN 1989 (n=476) AND 1997 (n=411)
91
81
71
61
51
41
31
21
11
1
44.5
19
1989
1997
PREVALENCE OF ANTI-HAV IN SAUDI
CHILDREN IN 1997 ACCORDING TO SEX
30
25.75
24
25
Percent
20
15
10
5
0
Male (n=2642)
Female (n=2713)
No. of children = 5355
PREVALENCE OF ANTI-HAV IN SAUDI CHILDREN IN 1997
ACCORDING TO LOCATION
33.04
35
30
Percent
25
20.98
20
15
10
5
0
Urban (n=3635)
Rural (n=1715)
No. of children = 5255
AGE SPECIFIC PREVALENCE OF ANTI-HAV IN SAUDIS
FROM RIYADH, CENTRAL REGION
Age
(Years)
1986
1994
P
No. Positive/
No. Tested
%
No. Positive/
No. Tested
%
1–9
103/194
53.0
81/210
38.6
3.4 x 10.3
10 – 19
164/193
85.0
110/180
61.1
1 x 10.4
20 – 30
182/200
91.0
188/240
78.3
3 x 10.4
Total
449/587
76.5
379/630
60.2
1 x 10.4
Arif et al. Saudi J Gastroenterology, 1995
Changing pattern of Hepatitis A prevalence
within the Saudi population over 18 yrs
60
50
53 *
40
30
24.3 **
20
18.1
***
10
0
1989
Age
Region
1-10 YRS
13
1999
2008
1-12 yrs
13
16-18 yrs
3
*AlRashed R. Ann SM 1997
** AlFaleh et al SMJ 1999
*** AlFaleh et al WJG 2008
THANK
YOU
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
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
Hepatitis C