HEPATITIS-

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HEPATITIS : 

1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 1 HEPATITIS Dr.Mohammad Khalid

INTRODUCTION : 

1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 2 INTRODUCTION Hepatitis is defined as a widespread damage to the liver hepatocytes with inflammatory changes. In acute hepatitis liver damage is centrilobular or widespread and may either result in limited or massive necrosis of the liver parenchyma resulting in liver failure. In chronic hepatitis there is long standing inflammation and replacement of liver parenchyma by fibrous tissue with loss of function ultimately leading to cirrhosis. Hepatitis is one of the major public health concern in Pakistan and Globally The World Health organization has estimated that more than 10 million people in Pakistan are suffering from Hepatitis, 4 to 5 million 5 are suffering from Hepatitis B and about four to six million people 5 from Hepatitis C. Five to seven per cent of the Pakistani population are patients of Hepatitis-C. Estimated 3.9 million (1.8%) Americans have been infected with HCV, of whom 2.7 million are chronically infected and Estimated 1.25 million chronically infected with HB

TOPICS OF DISCUSSION : 

1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 3 TOPICS OF DISCUSSION Liver – Structure and Function Types of Hepatitis Causes of Acute Hepatitis Causes Chronic Hepatitis Viral Hepatitis – A Review Prevention Strategies In Viral Hepatitis

LIVER – STRUCTURE AND UNCTION-1 : 

1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 4 LIVER – STRUCTURE AND UNCTION-1 The adult human liver normally weighs between 1.0 - 2.5 kilograms, and is a soft, pinkish-brown organ and lies in RHC The liver is supplied by two major blood vessels on its right lobe: the hepatic artery and the portal vein. The hepatic veins drain directly into the inferior vena cava. The liver is among the few internal human organs capable of natural regeneration of lost tissue; as little as 25% of remaining liver can regenerate into a whole liver again. It has two major lobes. These are made up of many small functional parenchymal units each with a branch of artery,vein and bile duct , the lobule. Functions: excretes bile ,carbohydrate metabolism ,lipid metabolism, produces coagulation factors, breaks down hemoglobin), toxic substances and most medicinal products, converts ammonia to urea. stores a multitude of substances, including glucose in the form of glycogen, vitamin B12, iron, and copper.

LIVER–STRUCTURE AND FUNCTION-2 : 

1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 5 LIVER–STRUCTURE AND FUNCTION-2 Posterior aspect

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 6 LIVER – STRUCTURE AND FUNCTION-3 Surgical view-in vivo

2: TYPES OF HEPATITIS : 

1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 7 2: TYPES OF HEPATITIS TWO MAJOR GROUPS 1: Acute Hepatitis A: Infective B: Non-infective 2: Chronic Hepatitis A: Infective B: Non-infective

3:CAUSES OF ACUTE HEPATITIS : 

1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 8 3:CAUSES OF ACUTE HEPATITIS VIRAL Hepatitis A virus Hepatitis B virus Hepatitis C virus Hepatitis D virus Hepatitis E virus Hepatitis G virus Cytomegalo, Epstein-Barr, Herpes Simplex, Yellow Fever viruses Post viral infection - Reye’s syndrome (Aspirin associated) Non-Viral infections Leptospirae (Icterohaemorrhagiae) Toxoplasma gondii Coxiella burneti Misc; – Amoebic , other bacterial Drugs Poisons (Mushrooms, Carbon tetrachloride ) Metabolic (Wilson’s disease , fatty change in pregnancy) Ischaemic (CCF,Budd-Chiari syndrome

4:CAUSES OF CHRONIC HEPATITIS : 

1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 9 4:CAUSES OF CHRONIC HEPATITIS Viral - B,C,D,G? Toxins – Alcohol , Drugs Biliary obstruction Primary biliary cirrhosis Secondary biliary cirrhosis – stricture , stone , neoplasms Primary sclerosing cholangitis Metabolic diseases Heamochromatosis – Primary and secondary Wilson’s disease Alpha-1 antitrypsin deficiency Hepatic congestion – (initially congestion then inflammatory swelling and then cirrhosis) budd chiari syndrome,CCF,Venous congestion Unknown – Autoimmune , cryptogenic

5: VIRAL HEPATITIS – A REVIEW : 

1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 10 5: VIRAL HEPATITIS – A REVIEW Viral hepatitis needs detail discussion as It is responsible for more than 90% cases of both acute and chronic hepatitis Very important from public health point of view – as preventable Types A and E cause only acute hepatitis and spread by feaco-oral route Types B,C,D and G cause both acute & chronic hepatitis and are transmitted by blood and blood products and body fluids

Etiological , clinical and treatment aspects of Viral hepatitis : 

1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 11 Etiological , clinical and treatment aspects of Viral hepatitis 1:HEPATITIS –A AGENT: Hepatitis A is a highly infectious enveloped RNA virus TRANSMISSION : HAV is transmitted fecal-orally and is acquired either by person-to-person contact or by the ingestion of contaminated food or water. Those persons newly infected with HAV are most contagious during the two weeks prior to the onset of jaundice. HAV remains viable in the environment for weeks to months; therefore, transmission can readily occur through close personal contact such as by sexual exposure or sharing contaminated communal surfaces such as toilets.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 12 Hepatitis A (contd) The following groups are more prone: Household contacts of infected persons Sex contacts of infected persons Persons, especially children, living in areas with increased incidence of hepatitis A Men who have sex with men Injecting and non-injecting drug users

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 13 Hepatitis A (contd) INCUBATION PERIOD : 30 days (range: 15-50 days). CLINICAL FEATURES : Patients may present with jaundice, dark urine, nausea, diarrhea, and severe malaise. Acute hepatitis A is usually a self-limited illness, but a small number of patients develop fulminant hepatitis. LONG-TERM EFFECTS : Acute hepatitis eventually resolves with the development of natural, lifelong immunity. However about 15% of people infected with HAV will have prolonged or relapsing symptoms over a 6-9 month period.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 14 Hepatitis A (contd) DIAGNOSIS : Acute hepatitis A is confirmed by a positive serum IgM anti-HAV titer that is detectable within 5-10 days after the onset of symptoms and persists for up to 6 months after infection. Previous HAV infection is evidenced by (IgG anti-HAV-positive or IgM anti-HAV-negative). False positive IgM anti-HAV test results have been reported. TREATMENT : No effective antiviral therapies are available for acute hepatitis A. Treatment efforts are largely supportive. Immunoglobulin in severe cases

2:HEPATITIS -B : 

1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 15 2:HEPATITIS -B AGENT:HBV is hepatitis B virus, a double-stranded DNA virus. ANTIGENS AND ANTIBODIES: HBsAg is hepatitis B surface antigen, a viral envelope antigen appears in late IP and remains for up to 6 months. In CLD it remains throughout. Anti-HBs is the antibody to hepatitis B surface antigen that confers immunity to HBV infection. Anti-HBs appears after 3-6 months of acute infection with HBV and following vaccination. In past infection Anti HBsAg+Anti HBc both are present but in post vaccination cases only Anti HBsAg is present. HBeAg is a secreted, viral antigen of the hepatitis B virus core that is indicative of active viral replication and increased infectiousness. It appears for a short time at the onset of the illness.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 16 Hepatitis B (contd) 4: Anti HBe: Appears late in acute illness and indicate cessation of viral replication . In CLD its presence is a good indicator and reflects either viral clearance or low replication. 5: IgM anti-HBc is the antibody to hepatitis B core antigen that develops at the onset of infection in acute HBV infection. HBcAg does not appear in the blood. 6: Total anti-HBc total antibody response to HB core antigen (IgM anti-HBc + IgG anti-HBc) detectable after acute HBV infection and convalescence. a useful screen for past HBV infection. Total anti-HBc is not detectable following hepatitis B vaccination. This may be the only sign of infection in the window period.

Hepatitis B (contd) : 

1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 17 Hepatitis B (contd) TRANSMISSION : HBV is a blood borne and sexually transmitted pathogen that is spread through : percutaneous and mucosal exposures to infected blood and body fluids, injection drug use, sexual intercourse with an infected partner, perinatal transmission from mother to child, chronic hemodialysis, Tattooing with shared, contaminated needles. HBV is viable for at least 7 days on environmental surfaces and can be transmitted by sharing contaminated household items such as razors and toothbrushes.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 18 Hepatitis B (contd) Persons with chronic hepatitis B infection (HBsAg-positive) are often asymptomatic, but can still transmit their infection to others. Contagiousness increases significantly if persons with chronic HBV infection are also hepatitis B e antigen-positive (HBeAg-positive). INCUBATION PERIOD : 90-120 days (range: 45-180 days). CLINICAL FEATURES : Acute hepatitis B occurs in approximately 30-50% of infected adults and may be mild, severe, or fulminant. Signs and symptoms of acute hepatitis include fever, jaundice, nausea, abdominal pain, and malaise. Arthritis, serum sickness, and a nonspecific rash may also occur with acute HBV infection and, when present, are helpful diagnostically.

Hepatitis B (contd) : 

1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 19 Hepatitis B (contd) LONG-TERM EFFECTS : The majority of adults (85-90%) acutely infected with HBV eventually clear HBsAg from the blood and develop antibodies to HBsAg (anti-HBs) that confer long-term protection from re-infection. A subset of persons (10-15%) acutely infected with HBV develop chronic HBV infection (HBsAg-positive for 6 months or longer). 5-10 % of people with Chronic HBV infection (HBsAg-positive) may get chronic hepatitis or asymptomatic chronic infection, or eventually clear the virus at a later stage. 1-5% Individuals with chronic HBV infection are at increased risk of developing decompensated cirrhosis and hepatocellular carcinoma (HCC).

Hepatitis B (contd) : 

1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 20 Hepatitis B (contd) DIAGNOSIS : RAISED ALT (range in Thousands units in children to hundreds in adults) SEROLOGY IN ACUTE HBV INFECTION: Early illness 1: HBsAg 2:Anti HBc (IgM) 3:HBeAg Late illness 1: Anti HBs 2:Anti HBc (IgG) 3:Anti HBe 4:HBS Ag for 6 months The diagnosis of chronic HBV infection is confirmed by the detection of hepatitis B surface antigen (HBsAg) on two separate occasions, 6 months apart; SEROLOGY IN CHRONIC HBV INFECTION: 1:HBS Ag 2:Anti HBc of IgG type 3:HBe Ag – indicate active viral replication 4:Anti HBe- Indicate either low replication or viral clearance

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 21 Hepatitis B (contd) TREATMENT : No effective therapies are available for acute hepatitis B, therefore treatment efforts are largely supportive. Approved antiviral therapies for chronic hepatitis B include interferon alfa-2b, pegylated interferon alfa-2a, adefovir dipivoxil, entecavir, and lamivudine. Treatment options for cirrhosis and HCC are limited and drug therapy mostly unrewarding. Liver transplantation is the only option but most expensive and not cost effective.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 22 3:HEPATITIS C AGENT: HCV is hepatitis C virus, an enveloped, single-stranded RNA virus. with 6 genotypes and more than 50 subtypes. TRANSMISSION :HCV is transmitted primarily by : direct percutaneous exposures to infectious blood, such as through injection drug use the transfusion of contaminated blood products HCV is inefficiently transmitted through sexual contact; however, persons with multiple sexual partners have an increased risk of acquiring HCV infection. from mother to child in approximately 5-6% of pregnant women who have chronic HCV infection at the time of delivery. Tattooing with contaminated needles HCV is not spread by kissing, sneezing, hugging, coughing, food or water, sharing eating utensils or drinking glasses, or other casual contact.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 23 Hepatitis C (contd) INCUBATION PERIOD : 6-7 weeks (range: 2-26 weeks); CLINICAL FEATURES : Acute HCV infection is often silent, evident if there is circumstantial evidence for new infection,such as a recent exposure to a known HCV-infected person or clinical features of acute hepatitis with the exclusion of other causes of hepatitis. Acute hepatitis C rarely causes fulminant hepatic failure. LONG-TERM EFFECTS : 50-85% with HCV develop chronic infection, 15- 50% of newly infected clear the virus spontaneously. 10-15% (70%) with chronic HCV infection develop progressive fibrosis of the liver leading to cirrhosis. Hepatocellular carcinoma (HCC) risk is about 1-4% / year. 5. Deaths from chronic liver disease: 1%-5%

Hepatitis C (contd) : 

1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 24 Hepatitis C (contd) DIAGNOSIS : ACUTE: 1) marked elevations in ALT (> 7 times) with or without symptoms of acute hepatitis; 2) negative tests for acute hepatitis A (IgM anti-HAV) and acute hepatitis B (IgM anti-HBc); and 3) a positive anti-HCV screening immunoassay (ICT,ELIZA, CIA) that is confirmed with either: an immunoassay! or a supplemental test, e.g., recombinant immunoblot assay (RIBA ). ® HCV RNA may be detected by PCR 1-3 weeks after exposure, but viremia may be transient, i.e., a negative qualitative HCV RNA does not preclude acute HCV infection.

Hepatitis C (contd) : 

1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 25 Hepatitis C (contd) TESTING RECOMMENDATIONS FOLLOWING A KNOWN EXPOSURE: 1) nucleic acid test for HCV RNA immediately after exposure, at week 4 and at week 12; 2) anti-HCV by EIA or CIA immediately after exposure and at week 12 3) serum ALT and AST immediately after exposure, at week 4 and 12. CHRONIC: A quantitative HCV nucleic acid test, however, is required before initiating antiviral therapy, If the quantitative HCV nucleic acid test is negative, the more sensitive qualitative HCV nucleic acid test (PCR) should be obtained.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 26 Hepatitis C (contd) TREATMENT: Reported data suggest that antiviral therapy is beneficial in treating persons with acute HCV infection; however, the timing and the optimal treatment regimen in this setting are uncertain. In one study, 52% of symptomatic individuals with acute hepatitis C spontaneously cleared the virus within 12 weeks. Of those who did not clear the virus, treatment initiated within 3-6 months of infection resulted in a sustained virological response in 81%. The combination of interferon plus ribavirin is significantly effective in clearing viremia and establishing sustained viral response rates SVR).

4:HEPATITIS D : 

1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 27 4:HEPATITIS D AGENT: HDV is hepatitis delta virus, a defective single-stranded RNA virus that requires HBV for structural integrity and replication. TRANSMISSION : HDV, also known as hepatitis delta virus, is transmitted through : blood , through injection drug usage. sexual transmission occurs, but is much less efficient than for HBV. perinatal transmission is rare. Areas of the world with a high prevalence of infection are Turkey, Egypt, Southern Italy, Spain, Russia, Romania, and the Amazon River Basin. INCUBATION PERIOD : 60-90 days (mean 30-180 days)

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 28 Hepatitis D (contd) CLINICAL FEATURES : jaundice ,fatigue,abdominal pain,loss of appetite , nausea, vomiting ,joint pain,dark (tea colored) urine NATURAL HISTORY : Acute HBV-HDV co-infection (concurrent infections with HBV and HDV) results in a severe acute hepatitis more frequently than infection with HBV alone, but progression to chronic infection is uncommon. HBV-HDV super infection (HDV infection acquired in a person with preexisting chronic HBV infection) results in chronic HDV infection and a higher risk for cirrhosis and hepatocellular carcinoma compared to persons infected with HBV alone.

Hepatitis D (contd) : 

1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 29 Hepatitis D (contd) DIAGNOSIS : Following HBV-HDV co-infection both IgM anti-HDV and IgG anti-HDV are detectable. IgM anti-HDV is more likely to be detectable during the acute illness; whereas IgG anti-HDV is more like to be present during convalescence, Following HBV-HDV super infection, chronic HDV infection with detectable HDAg usually occurs. Both IgM anti-HDV and IgG anti-HDV remain detectable. TREATMENT: Acute HDV infection Supportive care Chronic HDV infection interferon-alfa liver transplant

5:HEPATITIS E : 

1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 30 5:HEPATITIS E AGENT: Hepatitis E virus is a RNA virus TRANSMISSION : HEV is found in the stool (feces) of persons with hepatitis E. HEV is spread by eating or drinking contaminated food or water. Transmission from person to person occurs less commonly than with hepatitis A virus Most outbreaks in developing countries have been associated with contaminated drinking water. Pregnant women are more prone to develop HEV infection INCUBATION PERIOD : 14-60 days (mean 40 days)

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 31 HEPATITIS E (CONTD) CLINICAL FEATURES : Young ( 15 - 40 ) and pregnant women in 3rd trimester ( 10 -20 % mortality) are more prone Jaundice,fatigue,abdominal pain,loss of appetite,nausea, vomiting,dark (tea colored) urine LONG-TERM EFFECTS : None DIAGNOSIS : Virus detection in stool and anti HEV antibody (IgM) TREATMENT: Treatment is supportive

6:HEPATITIS G : 

1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 32 6:HEPATITIS G AGENT:HGV is RNA virus and is similar to HCV but only has 25 amino acids. The virus is named after GB a 34 year-old surgeon who contracted hepatitis and died from it.His serum was able to infect monkeys and the "GB agent" was passaged in monkeys over the years. In 1995-96 the virus was identified as a distinct virus different from other human hepatitis viruses (A, B, C, D, E) and was named after the surgeon as HGV Three genotypes of this virus were identified by investigators at Abbott Labs, and termed GB-A, GB-B and GB-C. GB-A and GB-B are likely tamarin viruses; GB-C can infect humans.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 33 HEPATITIS G (CONTD) PREVALENCE: in most of the studies prevalence is high and it is 1.2 - 3% HGV positive people. TRANSMISSION: is through 1: blood and blood products and 2: Sexual contact 3:IV drug abuse and other parenteral ways of infection,tatooing 4:transmission from infected mother to a child during the birth 5: possibility of transmission via saliva.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 34 HEPATITIS G (CONTD) CLINIAL FEATURES: 1:Hepatitis G virus infection is usually "clinically silent" or mild hepatitis and nearly always chronic 2:Progression to cirrhosis with chronic hepatitis G infection is probably very low. 3:Some studies report chronicity as high as HCV (up to 70 % ) 4:Nonhepatic manifestations of this virus may well exist DIAGNOSIS: Only PCR is available in Agha Khan and SKH and costs more than 2000 rupees per test TREATMENT: Mainly supportive. In HBC+HGV and HBV+HGV co-infection IFN + RBZL are effective.

5:PREVENTION STRATEGIES IN VIRAL HEPATITIS : 

1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 35 5:PREVENTION STRATEGIES IN VIRAL HEPATITIS HEPATITIS A GOLDEN RULE: Health education in the community is the main preventive measure. The main messages are: Always wash your hands with soap and water after using the bathroom, changing a diaper, and before preparing and eating food. No street (uncovered food) Control of local ice creams manufacturing Good sanitation and clean drinking water REPORTING: Ideally we should have an active surveillance system for notifiable infectious diseases. All cases of acute hepatitis A should be reported to health authorities and active preventive measures taken in response.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 36 HEPATITIS A (PREVENTION-CONTD) CONTAINMENT: The diseased person is contagious for 3 weeks before and 10 days after the onset of jaundice for containment and contact investigation purposes. Ideally those diagnosed with acute hepatitis A should be managed in accordance with the following guidelines: • Isolated in a room with separate sink and toilet until 10 days after the onset of jaundice and until clinically improving • Immediately removed from any assigned duties as a food handler • Counseled regarding strict hand washing and other practical infection control measures •Managed using standard precautions to prevent fecal-oral transmission when in contact with contaminated body fluids, including use of gloves CONTACT INVESTIGATION: (History and IgM anti HAV) Susceptible contacts include: Spouse, close personal contacts, and sexual contacts.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 37 HEPATITIS A (PREVENTION-CONTD) VACCINE ADMINISTRATION: Hepatitis A vaccine is a highly immunogenic vaccine that is administered intramuscularly in the deltoid or gluteal (upper outer quadrant) muscle in a two-shot series, 6-12 months apart depending on the vaccine preparation. The two brands of hepatitis A vaccine (HAVRIX® formulated with a preservative; and a bivalent combination vaccine, TWINRIX®, containing hepatitis A (HAVRIX®) and hepatitis B (ENGERIX-B®) antigens, is given on a 0, 1, 6-month schedule, and is equally effective. Vaccination of a person with previous immunity to HAV infection does not increase the risk of adverse events. Prevaccination serologic screening for prior immunity to HAV infection by detecting IgG or total anti-HAV may be cost-effective for those where HAV infection is endemic, as well as among those 50 years of age or older. Post vaccination serologic testing for immunity is not indicated since the hepatitis A vaccine is highly protective.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 38 HEPATITIS A (PREVENTION-CONTD) POST-EXPOSURE MANAGEMENT: INDICATIONS: The following susceptible contacts case of hepatitis A are candidates for post-exposure prophylaxis with serum immunoglobulin (IG): Family members of the diseased person persons routinely sharing toilet facilities very close contacts such as those who have shared eating utensils and cigarettes with the patient co-worker food handlers (if source-case was a food handler). ADMINISTRATION: Post-exposure prophylaxis is provided by passive immunization in accordance with the following guidelines: IG prophylaxis is not effective unless administered within 2 weeks of exposure. Exposed individuals with previously documented immunity or hepatitis A vaccination do not require IG prophylaxis. 3. Hepatitis A vaccination is not an effective post-exposure prophylaxis measure, but may be indicated for inmates at risk of future exposures in the context of an investigated outbreak.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 39 HEPATITIS B PRE=EXPOSURE PREVENTION MEASURES: INFECTION CONTROL: a: COMMUNITY EDUCATION: 1: About the blood spread routes 2: Use of barbers instruments. Barbers also to be trained 3:HCPs and fashion workers about injection and needle spread 4:About unsafe sexual behavior. Help from Khatibs and Imams can be used. 5:Elected representatives can be activated and used. b: PATIENT EDUCATION: All should be counseled about the importance of preventing blood exposures during activities of daily living, i.e., sharing toothbrushes and razors and through unsafe behaviors such as injection drug use, tattooing, ear piercing and sexual contact with others,no blood donations. 2: REPORTING: Ideally all cases of acute hepatitis B and chronic HBV infection should be reported to health authorities

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 40 HEPATITIS B (PREVENTION-CONTD) 3: CONTAINMENT: Those with acute hepatitis B and chronic HBV infection (HBsAg-positive) do not require isolation, but should be counseled on the specific measures necessary for preventing further transmission of HBV to others. Non-disposable, patient-care items must be appropriately cleaned, disinfected, or sterilized based on the use; and measures must be taken to prevent cross-contamination during patient care, e.g., dialysis, vascular access, cauterizing, and dental procedures. 4: HEMODIALYSIS: Infection control measures should be implemented CONTACT INVESTIGATIONS: Close contacts of IgM anti-HBc-positive patient should be tested for HBsAg. Aggressive "ring vaccination" of close contacts is warranted.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 41 HEPATITIS B (PREVENTION-CONTD) 5: VACCINE ADMINISTRATION: Hepatitis B vaccine is available as ENGERIX-B® or RECOMBIVAX HB® or with many other brand names. These products are interchangeable, i.e., a vaccination series begun with one product may be completed with the other. Hepatitis B vaccine is also available in a combined formulation with hepatitis A vaccine (TWINRIX®). Pregnancy should not be considered a contraindication as HBV itself poses a significant risk to the fetus or newborn. The three-dose vaccination series is ideally administered at 0, 1, and 4-6 months. Administration guidelines: There must be at least a 1. -month interval between doses #1 and #2; 2-month interval between doses #2 and #3; 4-month interval between doses #1 and #3. If a dose is delayed, the next dose should be administered without restarting ire series The vaccine is administered intramuscularly in the deltoid muscle. Post vaccination testing (anti-HBs) to determine antibody responder status is not routinely indicated for newly vaccinated

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 42 HEPATITIS B (PREVENTION-CONTD) POST-EXPOSURE MANAGEMENT: Those with percutaneous (e.g., injection drug use,tattooing, injury with needle or needle-like device contaminated with blood of unknown origin)or mucosal (e.g., sexual contact, human bites) exposures to blood warrant emergency evaluation for post-exposure prophylaxis. EMERGENCY CARE: Wounds and skin sites that have been in contact with blood or bloody body fluids should be washed with soap and water. Exposed mucous membranes should be flushed with water. Squeezing the wound and treating with topical antiseptics are not recommended. COUNSELING: Those with percutaneous or mucosal exposures to blood should be assessed by a health care provider and counseled regarding their risk of HBV infection, the natural history of HBV infection, and the recommendations for post-exposure prophylaxis.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 43 HEPATITIS B (PREVENTION-CONTD) VACCINE AND HBIG: Prompt post-exposure prophylaxis should be provided to those potentially exposed to HBV in accordance with the following: Unvaccinated persons should begin the vaccine series immediately and subsequent doses should be administered in accordance with standard practices. If the source of the exposure is HBsAg-positive, hepatitis B immunoglobulin (HBIG) 0.06 mL/kg body weight should also be administered to unvaccinated exposed inmates,as soon as possible, but <7 days after the exposure. Persons who have been fully vaccinated prior to an exposure to HBV ordinarily do not require post-exposure prophylaxis.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 44 HEPATITIS C PRE=EXPOSURE PREVENTIVE MEASURES There is no vaccine to prevent hepatitis C. HEALTH EDUCATION: Community should be educated about the importance of preventing blood exposures to others during activities of daily living such as injections,shaving and cutting hairs, not to sharing toothbrushes and razors and through unsafe behaviors such as injection drug use, tattooing, and sexual contact with others. HCV can be spread by sex, but this is rare. REPORTING: An active Surveillance system for notifiable infections with reporting of acute and chronic HCV to the health authorities to have an authentic database and for the planning of infection control in the community is a need of the day.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 45 HEPATITIS C (PREVENTION-CONTD) 4: CONTAINMENT & AVOIDANCE : Those with acute hepatitis C and chronic HCV infection do not require isolation, but should be counseled on the specific measures necessary for preventing further transmission of HCV to others. Non-disposable patient-care items must be appropriately cleaned, disinfected, or sterilized based on the use; measures must taken to prevent cross contamination during patient care, e.g., dialysis, vascular access,cauterizing, dental procedures, etc. 5: CONTACT INVESTIGATION: Contact investigations should be offered to close contact of acute hepatitis C patients but in our setting contacts are hardly possible to trace and difficult to relate to the patient as it is a highly endemic area and possibility of earlier infection cannot be ruled out.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 46 HEPATITIS C (PREVENTION-CONTD) POST-EXPOSURE MANAGEMENT: EMERGENT CARE: Wounds and skin sites that have been in contact with blood or bloody body fluids should be washed with soap and water. Exposed mucous membranes should be flushed with water. Squeezing the wound and treating with topical antiseptics are not recommended. COUNSELING: Those with percutaneous or mucosal exposures to blood should be assessed by a qualified health care provider and counseled regarding their risk of acquiring HCV infection, About the natural history of HCV infection, recommendations for post-exposure management.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 47 HEPATITIS C (PREVENTION-CONTD) POST-EXPOSURE FOLLOW-UP: No vaccine or passive immunization is available to prevent acquisition of HCV infection following an exposure. The following guidelines should be used for managing inmate exposures to HCV: Whenever feasible, the source of the exposure should be tested for anti-HCV, unless the source's infection status is already known. Measure anti-HCV by a ICT (confirmed by ELIZA, if positive) in the exposed inmate immediately after exposure and at week 12. Measure HCV RNA by ELIZA and PCR and ALT levels in the exposed inmate immediately after exposure, at week 4, and at 12. Those with evidence of newly acquired HCV infection should be appropriately counseled and referred for further medical evaluation including possible treatment for acute hepatitis C with IFN.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 48 HEPATITIS D HDV is a an incomplete virus and need HBV for clinical disease.Therefore preventive measures as discussed under HBV prevention secondarily also prevent HDV infection too. Community education, Reporting, Containment, Contact investigation and other measures as discussed under HBV apply here. It is worth mentioning here that suspected contacts should be tested for HBsAg in order to identify at-risk persons with chronic HBV infection (HBsAg- positive). In Short steps to be taken for the prevention of HDV are: 1: Hepatitis B vaccination (FOR HBs NEGATIVE PEOPLE) Hepatitis B vaccine should be given to prevent HBV/HDV co-infection 2:HBV-HDV co-infection (HERE HBs IS YET NEGATIVE) pre- or post-exposure prophylaxis (hepatitis B immune globulin or vaccine) to prevent HBV infection 3:HBV-HDV super-infection (HERE HBV IS ALREADY PRESENT) education to reduce risk behaviors among persons with chronic HBV infection

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 49 HEPATITIS E No vaccine available for the prevention of HEV Being a waterborne disease with feaco oral transmission the steps and measures as discussed under HAV prevention are also useful for HEV prevention. MAIN HEALTH EDUCATION MESSAGES ARE: Always wash your hands with soap and water after using the bathroom, changing a diaper, and before preparing and eating food Avoid drinking water (and beverages with ice) of unknown purity, uncooked shellfish, and uncooked fruits or vegetables that are not peeled or prepared properly. It is worth mentioning that transmission from person to person occurs less commonly than with hepatitis A virus As Hepatitis E is more severe among pregnant women, especially in third trimester therefore special precautions, health education and hygienic measures are required in this group.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 50 HEPATITIS G The disease is not yet fully understood No vaccine available Health education and community awareness can increase awareness about this virus and screening of those cases of hepatitis with mild hepatitis or chronic liver disease who are HAV,HBV,HCV negative can pick the silent unknown cases of the disease. As HGV is mainly transmitted by blood transfusion and blood products so proper screening is the most important means of HGV prevention but as a cheaper screening test is not available and so the possibility of silent spread is high. Good sexual behavior is an effective way of blocking this mode of transmission Use of disposable syringes and avoiding contaminated needles for ear piercing and tattooing are also effective measures. HBV vaccination can decrease the mortality and morbidity associated with HGV+HBV co-infection.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 51 MANAGEMENT OF OCCUPATIONAL EXPOSURES Definition of Health-Care Personnel and Exposure Health-care personnel (HCPs) are defined as persons (e.g., employees, students, contractors, attending clinicians, public-safety workers, or volunteers) whose activities involve contact with patients or with blood or other body fluids from patients in a health-care, laboratory, or public-safety setting. An exposure that might place HCP at risk for HBV, HCV, or HIV infection is defined as a percutaneous injury (e.g., a needlestick or cut with a sharp object) or contact of mucous membrane or nonintact skin (e.g., exposed skin that is chapped, abraded, or afflicted with dermatitis) with blood, tissue, or other body fluids that are potentially infectious In addition to blood and body fluids containing visible blood, semen and vaginal secretions also are considered potentially infectious For perinatal exposure to an HBsAg-, HBeAg-positive mother, a regimen combining HBIG and initiation of the hepatitis B vaccine series at birth is 85%--95% effective in preventing HBV infection Within a week HBV+HBIG for HBV and treatment with IFN for HCV with in 6 months of exposure are highly effective.

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1/8/2010 Dr.Mohammad Khalid 4th MPH PHSA Peshawar 52 THANKS FOR A VERY PATIENT LISTENING

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