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DRHARIFFADILLAHSpPD
Manycausesofhepatitis
Infectious
Bacterial
Parasitic
Viral
Noninfectious
Leptospirosis
Syphillis
Tuberculosis
Toxoplasmosis
Amebiasis
EpsteinBarr
HerpesSimplex
VaricellaZoster
Coxsackievirus
Rubella
YellowFever
Alcohol
Drugs
Viralagentsthatprimarilyor
exclusivelyinfecttheliver
HepatitisAvirus
Infectioushepatitis
HepatitisBvirus
Serumhepatitis
HepatitisCvirus
Parenterallytransmitted
HepatitisEvirus
Entericallytransmitted
HepatitisDvirus
CoinfectionwithHBV
HepatitisGvirus
Parenterallytransmitted
Infectious A
Viral
hepatitis
NANB
Serum B D
Parenterally
C transmitted
F, G,
? other
A
Source of
virus
Route of
transmission
Chronic
infection
Prevention
feces
fecal-oral
no
blood/
blood/
blood/
blood-derivedblood-derived blood-derived
body fluids body fluids body fluids
E
feces
yes
yes
no
Initiallaboratoryevaluationof
jaundicedpatient
TESTPERFORMED
MEASUREMENT
Urinebilirubin
Conjugatedbilirubin
Serumbilirubin
Conjugatedandunconjugatedbilirubin
Alanineaminotransferase(ALT)
Hepatocellulardamage
Aspartateaminotransferase(AST)
Heptocellulardamage
Alkalinephosphatase
Intrahepaticorextrahepaticobstruction
Prothrombintime,partial
thromboplastintime,plateletcount,
bleeding
Clottingmechanism
Bloodcountwithbloodsmearexam
Redbloodcellmorphology,parasites,
atypicallymphocytes
HEPATITIS A VIRUS
RNAPicornavirus
Singleserotypeworldwide
Acutediseaseandasymptomaticinfection
Nochronicinfection
Protectiveantibodiesdevelopinresponseto
infectionconferslifelongimmunity
Confirmed.Acasethatmeetstheclinicalcasedefinitionandislaboratory
confirmedoracasethatmeetstheclinicalcasedefinitionandoccursina
personwhohasanepidemiologiclinkwithapersonwhohaslaboratory
confirmedhepatitisA(i.e.,householdorsexualcontactwithaninfected
personduringthe1550daysbeforetheonsetofsymptoms).
HEPATITIS A - CLINICAL
FEATURES
Jaundice by
age group:
Rare complications:
<6 yrs
6-14 yrs
>14 yrs
<10%
40%-50%
70%-80%
Fulminant hepatitis
Cholestatic hepatitis
Relapsing hepatitis
Incubation period:
Average 30 days
Range 15-50 days
Infection
ALT
Response
IgM
IgG
Viremia
HAV in stool
Week
10
11
12
13
Feces
Serum
Saliva
Urine
100
102
104
106
108
1010
GLOBAL PATTERNS OF
HEPATITIS A VIRUS TRANSMISSION
Disease
Rate
Peak Age
of
Infection
High
Low to high
Early childhood
Person to person;
outbreaks uncommon
Moderate
High
Late childhood/
young adults
Person to person;
food and waterborne
outbreaks
Low
Young adults
Person to person;
food and waterborne
outbreaks
Travelers; outbreaks
uncommon
Endemicity
Low
Very low
Very low
Adults
Transmission
Patterns
GEOGRAPHIC DISTRIBUTION OF
HEPATITIS A VIRUS INFECTION
PREVENTING HEPATITIS A
Hygiene(e.g.,handwashing)
Sanitation(e.g.,cleanwatersources)
HepatitisAvaccine(preexposure)
Immuneglobulin(preandpostexposure)
HEPATITIS A VACCINES
Highly immunogenic
97%-100% of children, adolescents, and adults
HAVRIX
(GSK)
2 doses
360 EL.U.
Thailand
38,157
VAQTA
(Merck)
1 dose
25 units
New York
Vaccine
1-16 yrs
2-16 yrs
(95 % Cl)
94%
(79%-99%)
1,037
100%
(85%-100%)
Atleast58yearsamongadultsandchildren
Efficacy
Nocasesinvaccinatedchildrenat56yearsoffollow
up
Mathematicalmodelsofantibodydeclinesuggest
protectiveantibodylevelspersistforatleast20
years
Othermechanisms,suchascellularmemory,
maycontribute
COMBINED HEPATITIS A
HEPATITIS B VACCINE
ApprovedbytheFDAinUnitedStatesforpersons>18years
old
Contains720EL.U.hepatitisAantigenand
20g.HBsAg
Vaccinationschedule:0,1,6months
Immunogenicitysimilartosingleantigenvaccinesgiven
separately
Canbeusedinpersons>18yearsoldwhoneedvaccination
againstbothhepatitisAandB
Formulationforchildrenavailableinmanyothercountries
HEPATITIS A PREVENTION
IMMUNE GLOBULIN
Preexposure
travelerstointermediateandhigh
HAVendemicregions
Postexposure(within14days)
Routine
householdandotherintimatecontacts
Selectedsituations
institutions(e.g.,daycarecenters)
commonsourceexposure(e.g.,
foodpreparedbyinfectedfoodhandler)
HepatitisBVirus
HBV
HBVnomenclature
HBV:hepatitisBvirus
HBsAg:hepatitisBvirussurfaceantigen
HBcAg:hepatitisBviruscoreantigen
HBeAg:penandareplikasi
AntiHbe:replikasirendah
HBVEpidemiology
Horizontaltransmission
Persontopersonspread
Parenteral
Sexual
Verticaltransmission
Chronicallyinfectedmothertochild
Atbirthorviabreastmilk
HBVPathology
Portalofentry
Percutaneousismostefficient
Sexualorperinatalisless
efficientbutmajorsource
Intobloodstreamandtoliver
Hepatocytes
Littlecytopathology
Immunepathology
HBVEpidemiology
HBVClinicalSyndromes
ACUTEINFECTION
Incubationphase:long
Prodromalphase:insidious
Flulike:malaise,fatigue,anorexia,nausea,abdominaldiscomfort,
chills
Ictericphase:liverdamage:jaundice,darkurine,pale
stools
Recovery:declineinfever;renewedappetite
HBVDiagnosis
Clinical
Symptoms
LookslikeHAV
HBVDiagnosis
Laboratory
Liverenzymes
Serology
HBeAg,HBcAg,virus:activeinfection
AntiHBcIgM:acuteactiveinfection
AntiHBeIgG:acuteinfection
HBVTreatment
Supportive
Interferon:manysideeffects
Otherantiviraldrugs
Lamivudine:duringviral
infection
Famciclovir:reversetranscriptase
inhibitor
HBVComplications
Fulminatehepatitis
Chronichepatitis
5%10%ofHBVinfections
10%oftheseprogresstocirrhosis/liverfailure
Athigherriskforfulminanthepatitis
HBVComplications
ChronicHBsAgantigenemia
Postviral;asymptomaticcarrier
state;HBsAgonly
Chronicpersistenthepatitis(CPH)
Postviral;elevatedtransaminase;no
progressiontoliverdisease
Chronicactivehepatitis(CAH)
Postviral;progressestoliver
disease
Chroniclobularhepatitis(CLH)
Postviral;noprogressiontoliver
disease;elevatedtransaminase
levels
Livercirrhosis
Hepatocellularcarcinoma
2030yearsofpersistentHBV
infectionleadingtoliverinjury
HBVPrevention
Screenbloodproducts
Sterilizationofneedles,etc.
Avoidingintimatecontact,e.g.,
householdorsexualcontacts
Vaccination
Subunitvaccines
HBsAg