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Viral hepatitis may be defined as infection of the liver caused by any of the following viruses. Causative Agents; . Hepatitis A Virus (HAV), Hepatitis B virus (HBV) , C, D, E and G are recognized as aetiological agents of viral hepatitis. It is known that many other viruses may be implicated in hepatitis such as cytomegalovirus, Epstein-Barr virus, yellow fever virus and rubella virus. Viruses of herpes simplex, varicella and adenoviruses can also cause severe hepatitis in immuno-compromised individuals, but are rare. HEPATITIS A Hepatitis A (formerly known as "infectious" hepatitis or epidemic jaundice) is an acute infectious disease caused by Hepatitis A Virus (HAV). The disease is heralded by nonspecific symptoms such as fever, chills, headache, fatigue, generalized weakness, aches and pains followed by anorexia, nausea, vomiting, dark urine and jaundice. The disease spectrum is characterized by the occurrence of numerous sub clinical or asymptomatic cases. The disease is benign with complete recovery in several weeks. The case fatality rate of icteric cases is less than 0.1 per cent, usually from acute liver failure and mainly affects older adults. Agent factors
AGENT: The causative agent, the hepatitis A virus, is an entero virus (type 72) of the Picornaviridae family. It multiplies only in hepatocytes. Faecal shedding of the virus is at its highest during the later part of the incubation period and early acute phase of illness. Only one serotype is known, RESISTANCE: The virus is fairly resistant to heat and chemicals. It has been shown to survive more than 10 weeks in well water It withstands heating to 60 deg C for one hour, and is not affected by chlorine in doses usually employed for chlorination. Virus Disinfection Formalin is stated to be an effective disinfectant. The virus is inactivated by ultraviolet rays and by boiling for 5 minutes or autoclaving. RESERVOIR OF INFECTION: The human cases are the only reservoir of infection. The cases range from asymptomatic infections to severe ones. Asymptomatic (anicteric) infections are especially common in children. These cases play an important role in maintaining the chain of transmission in the community. There is no evidence of a chronic carrier state PERIOD OF INFECTIVITY: The risk of transmitting HAV greatest from 2 weeks before to 1 week after the onset jaundice. Infectivity falls rapidly with the onset of jaundice
INFECTIVE MATERIAL: It is mainly man's faeces. Blood serum and other fluids are infective during the brief stage viraemia. VIRUS EXCRETION: HAV is excreted in the faeces for about 2 weeks before the onset of jaundice and up to one week thereafter. The virus may also be excreted in urine
AGE: Infection with HAV is more frequent among children than in adults. However, susceptible people from all ages may be infected . In young children, infections tend to be mild or sub clinical; the clinical severity increases with age. SEX: Male and female, both sexes are equally susceptible, IMMUNITY: Immunity after attack probably lasts for life; second attacks have been reported in about 5 per cent of patients. Most people in endemic areas acquire immunity through sub-clinical infection The IgM antibody appears early in the illness and persists for over 90 days. IgG appears more slowly, and persists for many years.
Cases may occur throughout the year .The disease tends to be associated with periods of heavy rainfall Poor sanitation and overcrowding favors the spread of infection giving rise to water-borne and food-borne epidemics.
Modes of transmission
FAECAL -ORAL ROUTE: This is the major route of transmission. It may occur by direct (person-to-person contact or indirectly by way of contaminated water, food and milk. Water-borne transmission is not a major factor in developed countries, where food-borne outbreaks are becoming more frequent. Direct transmission comprises contaminated hands or objects such as eating utensils. Direct infection occurs readily under conditions of poor sanitation and overcrowding. PARENTERAL ROUTE: Hepatitis A is rarely, if ever, transmitted by the parenteral route (i.e., by blood and blood products or by skin penetration through contaminated needles). This may occur during the stage of viraemia. This mode of transmission is of minor importance. SEXUAL TRANSMISSION: As a sexually transmitted infection hepatitis A may occur mainly among homosexual men because of oral-anal contact
15 to 45 days (usually 25 to 30 days). The length of the incubation period is proportional to the dose of the virus ingested.
Diagnosis A specific laboratory diagnosis of hepatitis A can be obtained by a. Demonstration of HAV particles or specific viral antigens in the faeces b. Demonstration of a rise in anti-HAV titer c. Detection of IgM antibody to HAV in the patient's serum. This antibody appears
early in the illness, and persists for a limited time, usually for 3 to 4 months after onset; IgG antibody indicates past infection and immunity. Prevention and containment
. Control of reservoir:
Control of reservoir is difficult because of the following factors: (a) Faecal shedding of the virus is at its height during the incubation period and early phase of illness (b) The occurrence of large number of sub clinical cases in the community. (c) Absence of specific treatment, and (d) Low socio-economic profile of the population . Strict isolation of cases is not a useful control measure because of (a) and (b). Usual control measures such as notification, complete bed rest and disinfection of faeces and fomites should be done. The use of 0.5 per cent sodium hypochlorite has been strongly recommended as an effective disinfectant
Control of transmission:
The best means of reducing the spread of infection is by promoting simple measures of personal and community hygiene, e.g., hand washing before eating and after toilet; the sanitary disposal of excreta which will prevent contamination of water, food and milk
Control of susceptible population:
HUMAN IMMUNOGLOBULIN . It is recommended for (a) Susceptible persons traveling to highly endemic areas, (b) Close personal contacts of patients with HAV, (c) For the control of outbreaks in institutions
Several inactivated or live attenuated vaccines against hepatitis A have been developed, but only 4 inactivated hepatitis A vaccines are currently available internationally
HEPATITIS B Hepatitis B (formerly known as "serum" hepatitis) is an acute systemic infection with major pathology in the liver, caused by hepatitis B virus (HBV) and transmitted usually by the parenteral route. It is clinically characterized by a tendency to a long incubation period (6 weeks to 6 months) and a protracted illness with a variety of outcomes. Persistent HBV infection may cause progressive liver disease including chronic active hepatitis and hepatic-cellular carcinoma. Agent factors AGENT: Hepatitis B virus was discovered by Blumberg in 1963. Efforts to grow this virus have been so far unsuccessful. HBV is a complex, 42-nm, double-shelled DNA virus, originally known as the "Dane particle". It replicates in the liver cells. Hepatitis B virus Antigens; It has three distinct antigens - a surface antigen, also known as "Australia antigen" (HBsAg), a core antigen (HBcAg), and an "e" antigen (HBeAg). They stimulate the production of corresponding antibodies RESERVOIR OF INFECTION: Man is the only reservoir of infection which can spread either from carriers or from cases. The carriers of the virus, estimated to number over 350 million world-wide. The persistent carrier state has been defined as the presence of HBsAg for more than 9 months Cases may range from in apparent to symptomatic cases. The risk of an adult becoming a carrier following acute infection is 5 to 10 per cent; in infants, it may exceed 50 per cent INFECTIVE MATERIAL: Contaminated blood is the main source of infection, although the virus has been found in body secretions such as saliva, vaginal secretions and semen of infected persons. RESISTANCE: The virus is quite stable and capable of surviving for days on environmental surfaces. It can be readily destroyed by sodium hypochlorite, by heat sterilization in an autoclave for 30 to 60 minutes. PERIOD OF COMMUNICABILITY: The virus is present in the blood during the incubation period (for a month before jaundice) and acute phase of the disease. Period of communicability is usually several
months (occasionally years in chronic carriers) or until disappearance of HBsAg and appearance of surface antibody. Host factors AGE (a) In countries, where infection with HBV is common, much infection occurs perinatally or during early childhood (b) HIGH RISK GROUPS : Certain groups carry higher risks. For example, in USA, the annual incidence of HBV infection in surgeons is estimated to be 50 times greater than that in the general population, and is more than twice that of other physicians. Other high risk groups comprise recipients of blood transfusions, health care and laboratory personnel, homosexuals, prostitutes, and percutaneous drug abusers, infants of HBV carrier mothers and patients who are immuno-compromised. Serological screening and vaccination of high-risk groups is highly recommended, (c) HUMORAL AND CELLULAR RESPONSES: Antibodies form in a week or two after onset of jaundice - the order of being produced is , first core antibody, then "e" antibody and much later surface antibody. The appearance of surface antibody signals recovery from HBV infection and the development of immunity. Routes of Transmissions Parenteral Route; The main route of HBV transmission is through parenteral route. For that is more common in persons exposed to body puncture by needles. Perinatal transmission: Spread of infection from HBV carrier mothers to their babies appears to be an important factor for the high prevalence of HBV infection in some regions, particularly China and SE Asia Most infections appear to occur at birth, as a result of a leak of maternal blood into the baby's circulation, or ingestion or accidental inoculation of blood. Infection of the baby is usually anicteric and is recognized by the appearance of surface antigen between 60-120 days after birth Sexual transmission: There is ample evidence for the spread of infection by intimate contact or by sexual route. The sexually promiscuous, particularly male homosexuals are at very high risk of infection with hepatitis B. Other Routes: A, Transmission from child-to-child, often called horizontal transmission, is responsible for a majority of HBV infections and carriers in parts of the world other than Asia. The researchers believe that the spread occurs through physical contact between children with skin conditions such as impetigo and scabies, or with cuts or grazes. Often transmission occurs when children play together or share the same bed B, Transmission by blood sucking arthropods (e.g., mosquitoes, bed bugs) is suspected, but there is no convincing evidence to support this suggestion
Incubation period 45 to 180 days. Lower doses of the virus result often in longer incubation period. The median incubation period is said to be lower than 100 days Clinical picture The symptoms and manifestations of hepatitis B are similar to those of the other types of viral hepatitis. But the picture is complicated by the carrier state and by chronic liver disease, which may follow the infection. Chronic liver disease may be severe, and may progress to primary liver cancer which, in some parts of the world, is one of the commonest human cancers, particularly in men
PREVENTION AND CONTAINMENT Since there is no specific treatment, prevention has been the major aim in managing viral hepatitis B. The following measures are available:
. Hepatitis B vaccine
(i) PLASMA DERIVED VACCINE: This is based on the surface antigen (HBsAg) which is harvested and purified from the plasma of human carriers of hepatitis B virus. The final vaccine is a formalin inactivated sub-unit viral vaccine for intramuscular injection. Each 1.0 ml dose of the vaccine contains 20 micrograms of hepatitis surface antigen formulated in an alum adjuvant. The vaccine is given in 3 doses at 0, 1 and 6 months. An effective antibody response is generally attained after 3 doses in 95 per cent of vaccinees. Immunity continues at protective levels for approximately 3-5 years. Booster doses may be given after 3-5 years.
Hepatitis B vaccine: Immunization schedule 1 ml at elected date 1st dose 1 ml 1 month later 2nd dose 1 ml 6 months after the 3rd dose (booster) first dose Children under 10 years of age should be given half of above dosage at the same time intervals
Hepatitis B immunoglobulin (HBIG)
For immediate protection, HBIG is used for those acutely exposed to HBsAg-positive blood, for example (a) surgeons, nurses or laboratory workers (b) newborn infants of carrier
Passive-active immunization Simultaneous administration of HBIG and hepatitis B vaccine is more efficacious than HBIG alone. HBIG does not interfere with the antibody response to the hepatitis B vaccine. ; Combined procedure is ideal.
Other measures Blood Screening The blood donors should be screened for HBV infection, and serum positive for Australia antigen should be rejected, voluntary blood donation should be encouraged because purchased blood has shown a higher risk of post-transfusion hepatitis Health Specific Measures Health personnel should be emphasized to the importance of adequate sterilization of all instruments and simple hygienic measures. Disposable syringes should be used The Dentist should very much careful about sterilization. Cosmetic Measures The Equipment and materials used for puncturing the body, tattooing, ear and nose and genetalia puncturing should be properly sterilized. General Measure Each and every persons and especially carriers should not share razors or tooth brushes and use barrier methods of contraception. The carriers should not donate blood.
Hepatitis B is similar to hepatitis A in its symptoms, but is more likely to cause chronic long-term illness and permanent damage to the liver if not treated. How hepatitis B is spread The hepatitis B virus (HBV) is very common worldwide, with more than 350 million people infected. Those with long term HBV are at high risk of developing liver cirrhosis or liver cancer. Hepatitis B is most frequently passed on through the exchange of bodily fluids with an infected person. HBV is estimated to be 50 to 100 times more infectious than HIV.
HBV can be spread in the following ways: by unprotected (without a condom) penetrative sex (when the penis enters the anus, vagina or mouth) with someone who is infectious. Also by sex that draws blood with someone who is infected. by sharing contaminated needles or other drug-injecting equipment. by using non-sterilised equipment for tattooing, acupuncture or body piercing. from an infected mother to her baby, most commonly during delivery. Immunisation of the baby at birth prevents the transmission of hepatitis B. through a blood transfusion in a country where blood is not screened for blood-borne viruses such as HBV. Hepatitis B cannot be spread through sneezing, coughing, hugging or coming in contact with the faeces of someone who is infected. Signs and symptoms of hepatitis B Many people who become infected with HBV experience mild symptoms or no symptoms at all, but they may still carry the infectious virus and pass it on to others. When symptoms do appear they are similar to those of hepatitis A and may include: a short, mild, flu-like illness. nausea, vomiting and diarrhoea. loss of appetite. weight loss. jaundice (yellow skin and whites of eyes, darker yellow urine and pale faeces). itchy skin. If symptoms become severe then a person with hepatitis B may be admitted to hospital. Most adults infected with the hepatitis B virus fully recover and develop life-long immunity. Between 2% and 10% of individuals infected as adults will become chronic carriers, which means they will be infectious to others and can develop chronic liver damage. Infected children, especially newborn babies, are much more likely to become chronic carriers. If a person lives with hepatitis B infection for a number of years then they may develop the following complications: chronic hepatitis. liver cirrhosis. liver cancer. Where to go for help
If you have any symptoms or you are worried you may have been infected with hepatitis B, you should discuss your worries with a doctor. They may be able to run tests themselves, or else will refer you to someone who can. Some countries have specific sexual health clinics that can help you directly. What does a positive test result mean? A positive test result could indicate either of the following: A past infection. This means the patient has already been in contact with hepatitis B and their immune system has succeeded in fighting off the virus. The patient will then have a natural immunity to the virus. The patient is a carrier. This means the patient is carrying HBV and can pass it on to others. The person may not display any symptoms but could be at risk of developing chronic liver disease. A doctor may perform a number of different types of test to distinguish between current and past infections, and to estimate how infectious a patient with a current infection may be. What does a negative test result mean? This result generally means the patient has never been infected with HBV and therefore has no natural immunity against the virus. If the person suspects they may have been recently exposed to HBV, the doctor may advise them to take a repeat test to confirm their negative status, and may also advise immunisation against hepatitis B. Treatment In most countries a patient with a positive test result will be referred to a specialist who will carry out further tests to determine the degree to which hepatitis B may be affecting the liver, and what may be the best treatment options. In these tests a small sample of liver tissue may need to be taken (a liver biopsy). In the majority of patients with active HBV, symptoms will not be severe and treatment will not be required. The patient will be monitored and after a few months the patient’s immune system should fight off the virus, giving the patient natural immunity. In around 5% of adults, 30-50% of young children (aged 1-4), and 90% of infants, HBV infection will become chronic. The virus is more deadly to the young and those that are infected at birth have a 25% chance of developing a life-threatening liver-related illness. Antiviral medication is given as treatment to those with chronic symptoms to help prevent further liver damage. These medications may be injected or given in pill form. Examples are Interferon Alpha, Lamivudine and Baraclude. Treatment usually lasts 6 months, during which the patient will be carefully monitored.
Regardless of whether the infection is producing symptoms or not, the patient will be advised to avoid alcohol, get plenty of rest and maintain a healthy diet. Immunisation Three immunisation injections are given over a period of 3-6 months. A blood test is taken once the course of injections is completed to check that they have worked. Immunity should last for at least 5 years. Follow-up A patient with an active infection will be advised to have regular blood tests and physical check-ups to monitor the virus, even if they are not receiving treatment. All carriers of HBV should expect to be referred to specialist services. The doctor or nurse may advise the patient to avoid alcohol, fatty foods and follow a low-salt diet. They will also describe any precautions necessary to ensure that the patient avoids infecting others with the virus, such as not sharing toothbrushes or shaving equipment. It is most important to use a condom for penetrative sex to prevent passing on the virus. Sexual partners of the patient should be tested and immunised against HBV (if not already infected). (Source: http://www.avert.org/)